Risk factors for recurrence of chronic subdural hematoma after surgical evacuation: a systematic review and meta-analysis

Liquid Embolic Volume Correlates With Improved Chronic Subdural Hematoma Resolution After Middle Meningeal Artery Embolization

BACKGROUND AND OBJECTIVE

The efficacy of middle meningeal artery (MMA) embolization for chronic subdural hematomas (cSDH) has been widely demonstrated in the literature. However, the role of distal embolic penetration on incidence of cSDH resolution remains controversial. In this study, we examined the effect of number of branches embolized and volume of embolic material used on the incidence of radiographic clearance of cSDH.

METHODS

This is a retrospective review of all MMA embolizations performed at our institution for the treatment of cSDH. Baseline characteristics and technical parameters, including branches embolized and volume of embolic material used, were compared between patients with and without radiographic cSDH resolution at last follow-up. Further comparisons in outcomes were made between patients with multiple distal MMA branches embolized and those with a single branch embolized. Univariate statistical analysis was performed.

RESULTS

A total of 131 MMA embolizations in 104 patients performed at our institution were included. Of the 131 cSDH, 70 (53.4%) showed complete radiographic resolution at last follow-up. Persistent cSDH was associated with older age (P = .01), kidney disease (P = .001), and larger subdural size (P = .03). There was no difference in proportion of cSDH resolution between those with both anterior and posterior MMA branches embolized and those with a single branch embolized. However, the volume of embolic material used was significantly associated with subdural resolution (P = .04).

CONCLUSION

The volume of embolic material used during MMA embolization was significantly associated with radiographic cSDH resolution at last follow-up, while the number of MMA branches embolized did not affect cSDH resolution. Selection of MMA branches for better penetration of areas supplying the cSDH while minimizing the risk of reflux into nontarget branches can be considered in future optimization of this procedure.

Outcomes After Standardized Burr-Hole Surgery for Chronic Subdural Hematomas: A Population-Based Consecutive Cohort Study of 2655 Patients

BACKGROUND AND OBJECTIVES

Chronic subdural hematoma (CSDH) is one of the most common neurosurgical conditions. However, current evidence on postoperative outcomes exhibits variability due to small sample sizes, nonstandardized outcome assessment, and variations in surgical techniques. The aim of this study was to overcome these limitations by assessing standardized outcome measures after surgical intervention for CSDH at a high-volume population-based center favoring a uniform burr-hole craniotomy (BHC) approach.

METHODS

Adult patients (≥15 years) who underwent surgical treatment of a CSDH at the Karolinska University Hospital from 2006 to 2022 were retrospectively included. Outcome measures included 6-month ipsilateral hematoma reoperation, postoperative complications categorized by the Landriel-Ibanez grading system, neurological function, and mortality. Predictors of outcomes were assessed using multivariable logistic regression models.

RESULTS

In total, 2655 patients were included, with 2407 evacuated using BHC and 248 requiring a minicraniotomy. Reoperation for a hematoma recurrence occurred in 11%. Independent predictors of reoperation were male sex, diabetes, preoperative antithrombotic therapy, midline shift, and bilateral surgery. Postoperative complications occurred in 11% of cases, with 3.9% classified as moderate to severe. A complication leading to death was reported in 22 patients (0.8%). The most common postoperative complications were urinary tract infections (1.5%), subdural empyema (1.4%), and seizures (0.7%). Independent predictors of moderate-to-severe complications were higher preoperative Charlson Comorbidity Index and lower Glasgow Coma Scale score. The 1-year postoperative mortality rate was 12%.

CONCLUSION

This study provided standardized outcome measures in a large cohort of patients treated for CSDH at a center where BHC was consistently used. Most postoperative complications were mild and either did not require intervention or were managed with pharmacological treatment. The identified predictors of CSDH reoperation and moderate-to-severe postoperative complications offer considerations for clinical management and patient care.

Middle meningeal artery embolization with standalone or adjunctive coiling for treatment of chronic subdural hematoma: Systematic review and meta-analysis

INTRODUCTION

Middle meningeal artery embolization (MMAe) is increasingly utilized as a primary or secondary treatment for chronic subdural hematoma (cSDH) and is usually performed with liquid embolics or particles. Outcomes after MMAe with coiling as a standalone treatment, or an adjunct to other agents, have not been reviewed.

METHODS

A systematic review of the literature was performed to identify all original research that included patients who underwent standalone or adjunctive coiling for MMAe. The primary outcome was the need for rescue treatment defined as any unplanned reintervention for recurrent or residual cSDH.

RESULTS

A total of 10 studies comprising 346 patients (mean age 73 years, 39% female) who underwent MMAe with coils were included. The majority of embolizations were with coils and particles (n = 176), followed by standalone coiling (137) and coiling with liquid embolics (120). The pooled rate of rescue treatment after embolization was 9.4% (95% CI 6.4-13.6, I2 = 0). The pooled complication rate was 2.6% (95% CI 1.3-5.1, I2 = 0). In the subgroup analysis of four studies reporting results after standalone coiling, the pooled rescue treatment rate was 8.2% (95% CI 4.0-15.9, I2 = 0) and there were no complications.

CONCLUSION

MMAe with coils is safe and potentially effective, but additional studies evaluating long-term clinical and radiographic results after standalone coiling are needed.

Prediction of Postoperative Recurrence of Chronic Subdural Hematoma Using Preoperative Systemic Immune Inflammation Index and Eosinophils

Objective  Chronic subdural hematoma (CSDH) is a common neurological problem with significant recurrence after surgery. Risk considerations can vary, ranging from patient-related factors to those related to the surgical procedure. This study explores the association between preoperative eosinophil count and systemic immune inflammation (SII) with CSDH recurrence. Materials and Methods  We conducted a prospective analysis of 105 patients with equal numbers of CSDHs who underwent surgery for CSDH between January 2023 and January 2024. The preoperative eosinophil counts, along with other differential leukocyte counts, were measured. The SII index was calculated using the standard formula (SII = neutrophil count  ×  platelet count/lymphocyte count). Multivariate and univariate regression analyses were performed to assess the association between risk factors and CSDH recurrence. Results  The preoperative eosinophil count showed a significant correlation with recurrence ( p  < 0.001). The SII index was significantly higher in patients with recurrent CSDH ( p  = 0.003). Neutrophils were found to be significantly associated with CSDH recurrence ( p  = 0.038). Age ( p  < 0.001) and SII ( p  = 0.005) were found to be independent predictors of CSDH recurrence, whereas hematoma volume ( p  < 0.001) and the antiplatelet regimen were a significant predictor of CSDH recurrence ( p  = 0.047). Variables like male gender, diabetes mellitus, anticoagulants, and hematoma volume were associated with eosinophil-rich or eosinophil-poor status. Conclusion  Preoperative eosinophil count, neutrophils, and the SII index may serve as potential predictors of CSDH recurrence. Further studies with larger sample sizes are needed to validate these findings.

Development of a predictive model for assessing the risk factors associated with recurrence following surgical treatment of chronic subdural hematoma

Background

Chronic subdural hematoma (CSDH) is a common disease in neurosurgery. Although many studies have investigated the factors affecting the recurrence of CSDH, no comprehensive prediction model has been established for the risk effect of postoperative recurrence of the disease.

Objective

This study aims to collect and analyze the data of CSDH patients treated in our hospital to determine the influence of preoperative, postoperative and treatment factors on the recurrence of CSDH, and to establish a corresponding prediction model to provide neurosurgeons with more accurate basis for identifying high-risk patients and guiding treatment.

Methods

A total of 431 patients were collected in this study, including 323 patients who underwent traditional hematoma removal and 108 patients who underwent endoscopic hematoma removal. Relevant preoperative and postoperative data and medical history of patients were collected respectively to study the relevant factors affecting postoperative hematoma recurrence of patients, and to establish a prediction model.

Results

A total of 431 patients were enrolled in this study, 71 of whom had subdural blood recurrence. Possible relevant factors were included in univariate logistic regression, and the results showed that the preoperative GCS score, postoperative residual gas, preoperative CT hematoma thickness, coagulation function, unilateral and bilateral surgery, whether statin was taken after surgery, hematoma site, hematoma density and hematoma volume were all P < 0.2. It is a risk factor for recurrence of chronic subdural hematoma. The obtained data were further included in a multi-factor review. Six factors, including preoperative GCS score, postoperative gas residual, abnormal coagulation function, high-density hematoma, large hematoma volume, and irregular statin use after surgery, were independent risk factors for chronic subdural hematoma recurrence (P < 0.05).

Conclusion

This study confirmed that six factors, including preoperative GCS score, postoperative gas residual, abnormal coagulation function, high-density hematoma, large hematoma volume, and irregular statin use, were independent risk factors for recurrence of chronic subdural hematoma. At the same time, long-term use of statins can reduce the recurrence rate of hematoma to a certain extent. In addition, the predictive model in this study could help neurosurgeons accurately identify high-risk CSDH patients.

Risk Factors Associated With Seizure After Treatment of Chronic Subdural Hemorrhage: A Systematic Review and Meta-Analysis

BACKGROUND AND OBJECTIVES

Chronic subdural hemorrhage (cSDH) is a prevalent neurosurgical pathology, marked by blood collection between the dura mater and the arachnoid membrane. The aim of this systematic review was to provide a comprehensive overview of the risk factors associated with seizures after cSDH treatment.

METHODS

We systematically searched the following databases for studies conducted until September 28, 2023: PubMed, Embase, SCOPUS, Cochrane Central, WOS, and EBSCO. We selected all studies aiming to assess risk factors associated with seizures after treatment of cSDH. Observation studies written in English, Spanish, and Portuguese were included. The quality of studies was assessed using the Newcastle-Ottawa scale for observational studies.

RESULTS

A total of 1830 studies were screened after the elimination of duplicates. A total of 18 studies were included, representing 4966 patients. The pooled proportion of seizures after treatment of cSDH is 10% [95% CI 7%, 13%; I2 = 93%]. The risk of seizures was lower in patients undergoing burr hole surgery compared to craniotomy, with an odds ratio of 0.23 (95% CI [0.10, 0.55]; I2 = 0%). Additionally, the risk of seizures in patients receiving prophylactic antiepileptic treatment compared to those without was higher, with an odds ratio of 2.62 (95% CI [0.53, 13.06]; I2 = 66%).

CONCLUSION

Burr-hole treatment after cSDH presents a lower risk of seizures compared with craniotomy, and the use of prophylactic antiepileptic treatment did not conclusively affect seizure outcomes. Standardization in the reporting of outcomes and more comparative studies are needed to enable better recognition of risk factors of seizures after cSDH treatment.

Surgical treatment and recurrence of chronic subdural hematoma

Background: The incidence of chronic subdural hematoma (CSDH) is increasing owing to the rapid growth of the elderly population. CSDH causes various neurological symptoms such as cognitive impairment and motor dysfunction, which can improve with appropriate surgical management.Current Concepts: CSDH usually comprises a hemorrhagic fluid that accumulates within the subdural space and compresses the brain. Surgery is indicated if CSDH is associated with neurological symptoms and is aimed at safe and sufficient drainage of the hematoma. Currently, the recommended primary surgical method involves insertion of a draining catheter after burr hole or twist-drill trephination to facilitate drainage of the hematoma over a couple of days. Craniotomy is limited to cases of organized or calcified hematoma. The postoperative recurrence rate is approximately 10% to 20%. The same treatment method is attempted in cases of recurrence.Discussion and Conclusion: Surgical methods aim for rapid symptom relief and minimal invasiveness. Trephination and indwelling subdural catheter placement can enable immediate drainage of the hematoma and can be performed under local anesthesia. Preoperatively, it is necessary to obtain an accurate medical and medication history of elderly patients. Except in cases of emergencies, it is preferable to select the timing of the surgery only after reversal of the effects of drugs to prevent surgical complications in patients who receive anticoagulants or antiplatelet agents. Close postoperative follow-up is necessary in elderly patients because insufficient brain expansion leads to maintenance of the subdural space and is associated with a high risk of recurrence.