Chronic subdural haematomas are more common on the left than on the right

Surgical treatment and outcome of chronic subdural hematoma: a comparative study between Ethiopia and Norway

BACKGROUND

Chronic subdural hematoma (CSDH) is one of the most common neurosurgical conditions. Here, we studied differences in demographics, treatment, and outcome for CSDH patients in low-income (Ethiopia) and high-income (Norway) countries and assessed potential outcome determinants.

METHODS

We included patients from Addis Ababa University Hospitals (AAUH) and Haukeland University Hospital (HUH) who had surgery for CSDH (2013-2017). Patients were included prospectively in Ethiopia and retrospectively in Norway.

RESULTS

We enrolled 314 patients from AAUH and 284 patients from HUH, with a median age of 60 and 75 years, respectively. Trauma history was more common in AAUH (72%) than in HUH patients (64.1%). More patients at HUH (45.1%) used anticoagulants/antiplatelets than at AAUH (3.2%). Comorbidities were more frequent in HUH (77.5%) than in AAUH patients (30.3%). Burr hole craniostomy under local anesthesia and postoperative drainage was the standard treatment in both countries. Postoperative CT scanning was more common at HUH (99.3%) than at AAUH (5.2%). Reoperations were more frequent at HUH (10.9%) than at AAUH (6.1%), and in both countries, mostly due to hematoma recurrence. Medical complications were more common at HUH (6.7%) than at AAUH (1.3%). The 1-year mortality rate at HUH was 7% and at AAUH 3.5%. At the end of follow-up (> 3 years), the Glasgow Outcome Scale Extended (GOSE) score was 8 in 82.9% of AAUH and 46.8% of HUH patients.

CONCLUSION

The surgical treatment was similar at AAUH and HUH. The poorer outcome in Norway could largely be explained by age, comorbidity, medication, and complication rates.

Middle Meningeal Artery Embolization for Chronic Subdural Hematoma: A National Database Study of 191 Patients in the United States

BACKGROUND

Middle meningeal artery embolization (MMAE) has been used as an effective minimally invasive treatment for chronic subdural hematoma (cSDH). The demographics and clinical outcomes after MMAE treatment for cSDH have not yet been studied using a national database.

METHODS

We queried all MMAE cases up to October 7, 2020, from the TriNetX Analytics Network. We identified patients >18 years old who underwent MMAE for treatment of cSDH. Patient demographics, baseline characteristics, comorbidities, and clinical outcomes were evaluated within 180 days after MMAE. Analyses of 180-day mortality and recurrence were performed after propensity score matching to control for baseline characteristics and comorbidities.

RESULTS

The study included 191 patients (mean age 71.2 ± 13.5 years, 73.3% male, 69.6% White, 13.6% Black/African American, and 16.8% other race). Essential hypertension (71.3%), heart disease (62.8%), type 2 diabetes mellitus (27.2%), nicotine dependence (23.6%), chronic kidney disease (19.4%), and overweight/obesity (19.4%) were among the most prevalent comorbidities. At presentation, 20.4% and 40.3% of patients were on antiplatelet and anticoagulation therapy, respectively. Outcomes within 180-day follow-up were 6.3% (1.0%-5.8% when propensity matched) for mortality (12 patients), 7.3% for craniotomy/craniectomy after MMAE (14 patients), 0.52%-5.2% for burr hole procedures (1-10 patients), and no patients with low vision/blindness.

CONCLUSIONS

MMAE is a safe and effective minimally invasive procedure for treatment of cSDH. This is the first analysis of patients undergoing MMAE for cSDH using a national database.

Association between cranial asymmetry severity and chronic subdural hematoma laterality

Objectives:

To analyze the association between cranial asymmetry severity and chronic subdural hematoma (CSDH) laterality.

Methods:

We retrospectively assessed 120 patients with surgically treated unilateral CSDH from January 2009 to December 2018. Preoperative computed tomography images were used to determine occipital vault angles, bilateral cranium areas, and cranial index of symmetry (CIS) ratios.

Results:

The male sex (70%) was the predominant factor promoting CSDH pathogenesis. In the overall study population (mean age, 71.3 years; left-sided CSDH, 58/120 [48%] patients; right-sided CSDH due to right-sided flat cranium, 38 patients; left-sided CSDH due to right-sided flat cranium, 37 patients). Flat cranial asymmetry was nonsignificantly associated with CSDH laterality (p- value=.689). However, most CSDH patients (86.7% of 120 patients) presented dominant-sided nonoverlapping areas on the left side. Thirteen (81.3%) patients presenting right-dominant nonoverlapping areas had right-sided CSDH, and 55 (52.9%) patients had left-dominant nonoverlapping area had left-sided CSDH (p- value=0.01). The CIS ratio was significantly higher in patients with right-dominant nonoverlapping areas than in those with left-dominant nonoverlapping areas (97.2% vs 95.9%, p- value<0.0001).

Conclusion:

Left-sided hematoma predominance is not associated with a flat cranium and laterality of unilateral CSDH. Moreover, more asymmetric crania with lower CIS ratios may predict left-sided CSDHs, whereas the right-sided CSDHs may be more common in symmetric crania with higher CIS ratios. The CSDH laterality is potentially attributable to cranial asymmetry severity.

Chronic Subdural Hematoma (cSDH): A review of the current state of the art

Introduction

Incidence of Chronic Subdural Hematoma (cSDH) is rising worldwide, partly due to an aging population, but also due to increased use of antithrombotic medication. Many recent studies have emerged to address current cSDH management strategies.

Research question

What is the state of the art of cSDH management.

Material and methods

Review.

Results

Head trauma, antithrombotic use and craniocerebral disproportion increase the risk of cSDH development. Most patients present with disorientation, GCS 13–15, and symptoms arising from cortical irritation and increased intracranial pressure. cSDH occurs bilaterally in 9–22%. CT allows assessment of cerebral compression (herniation, hematoma thickness, ventricle collapse, midline shift), hematoma age and presence of membranes, factors that ultimately determine treatment urgency and surgical approach. Recurrence remains the principle complication (9–33%), occurring more commonly with older age and bilateral cSDHs.

Discussion and conclusion

While incompletely understood, it is generally believed that injury in the dural cell layer results in bleeding from bridging veins, resulting in a hematoma formation, with or without a preceding hygroma, in a potential space approximating the junction between the dura and arachnoid. Neovascularization and leaking from the outer membrane are thought to propagate this process. Evidence that MMA embolization may reduce recurrence rates is a potentially exciting new treatment option, but also supports the theory that the MMA is implicated in the cSDH pathophysiology. The use of steroids remains a controversial topic without clear treatment guidelines. cSDH represents a common neurosurgical problem with burr-hole treatment remaining the gold standard, often in conjunction with subgaleal drains. MMA embolization to stop recurrence may represent an important evolution in understanding the pathophysiology of cSDH and improving treatment.

•

Incidence of cSDH is rising, partly due to the aging population and increased antithrombotic use.

•

cSDH occurs bilaterally in 9–22% of cases.

•

Recurrence remains the principle complication and has been estimated at 9–33%.

•

Risk factors for recurrence include old age and bilateral cSDHs.

•

MMA embolization may reduce recurrence, but its efficacy and target population remain unclear.

[Surgical treatment of chronic subdural hematoma in Guinea: Analysis of 22 cases at the Kipe hospital of Conakry]

OBJECTIVE

We report the results of surgical treatment of chronic subdural hematoma in the Kipe Hospital in Conakry, Guinea, for the period July 2012 to November 2015.

MATERIAL AND METHOD

Clinical, radiological and therapeutic data from 22 cases were collected retrospectively and analyzed, with a mean follow-up of 61.6 days. Univariate analysis screened for factors for neurological outcome on the Markwalder Grading Scale (MGS; 0=normal to 4=coma).

RESULTS

Male-female sex ratio was 2.6:1. Mean age at diagnosis was 71.09±8 years, with peak incidence of CSDH in the 60-79 age group. Traumatic brain injury was identified as causal in 40.9% of cases. Burrhole trepanation was used in 86.36% of cases, under local anesthesia in 76%, and with postoperative drainage in all cases. No recurrences were recorded. At follow-up, mean postoperative MGS was 0.59 (up from 3.08 preoperatively); 54.54% of patients had normal neurological examination (grade 0). Age 60-79 years, time to diagnosis>12 weeks and preoperative MGS≥3 had significant negative impact on outcome (respective P-values: 0.03, 0.001, 0.001).

CONCLUSION

Our data were similar to those of the literature, but with longer time to diagnosis and poorer initial clinical status, with negative impact on clinical progression.

Present epidemiology of chronic subdural hematoma in Japan: analysis of 63,358 cases recorded in a national administrative database

OBJECTIVE

Aging of the population may lead to epidemiological changes with respect to chronic subdural hematoma (CSDH). The objectives of this study were to elucidate the current epidemiology and changing trends of CSDH in Japan. The authors analyzed patient information based on reports using a Japanese administrative database associated with the diagnosis procedure combination (DPC) system.

METHODS

This study included patients with newly diagnosed CSDH who were treated in hospitals participating in the DPC system. The authors collected data from the administrative database on the following clinical and demographic characteristics: patient age, sex, and level of consciousness on admission; treatment procedure; and outcome at discharge.

RESULTS

A total of 63,358 patients with newly diagnosed CSDH and treated in 1750 DPC participation hospitals were included in this study. Analysis according to patient age showed that the most common age range for these patients was the 9th decade of life (in their 80s). More than half of patients 70 years old or older presented with some kind of disturbance of consciousness. Functional outcomes at discharge were good in 71.6% (modified Rankin Scale [mRS] score 0–2) of cases and poor in 28.4% (mRS score 3–6). The percentage of poor outcomes tended to be higher in elderly patients. Approximately 40% of patients 90 years old or older could not be discharged to home. The overall recurrence rate for CSDH was 13.1%.

CONCLUSIONS

This study shows a chronological change in the age distribution of CSDH among Japanese patients, which may be affecting the prognosis of this condition. In the aging population of contemporary Japan, patients in their 80s were affected more often than patients in other age categories, and approximately 30% of patients with CSDH required some help at discharge. CSDH thus may no longer have as good a prognosis as had been thought.

No Value of Routine Brain Computed Tomography 6 Weeks after Evacuation of Chronic Subdural Hematoma

Background  The aim of this study was to evaluate the value of planned control postoperative brain computed tomography (CT) scan performed 4 to 6 weeks after the evacuation of chronic subdural hematoma.

Materials and Methods  This retrospective study examined 202 patients who during a 2-year period from 2011 and 2012 underwent surgical treatment for chronic subdural hematoma (CSDH). Information on patient age, sex, alcohol consumption, anticoagulant/antiplatelet treatment, history of head trauma, Glasgow coma scale (GCS), neurological symptoms, laterality of CSDH, and surgical technique was retrieved from patient charts.

Results  Overall, 27 out of 202 patients had a recurrence of CSDH and re-evacuation of the hematoma was performed. In all patients recurrence of neurological symptoms preceded the planned postoperative control brain CT 4 to 6 weeks after primary surgery.

Conclusion  Routinely postoperative control brain CT scan 4 to 6 weeks after the evacuation of a CSDH has no clinical value.

Bilateral chronic subdural hematoma: unilateral or bilateral drainage?

OBJECTIVE

Bilateral chronic subdural hematoma (bCSDH) is a common neurosurgical condition frequently associated with the need for retreatment. The reason for the high rate of retreatment has not been thoroughly investigated. Thus, the authors focused on determining which independent predictors are associated with the retreatment of bCSDH with a focus on surgical laterality.

METHODS

In a national database of CSDHs (Danish Chronic Subdural Hematoma Study) the authors retrospectively identified all bCSDHs treated in the 4 Danish neurosurgical departments over the 3-year period from 2010 to 2012. Univariate and multivariate analyses were performed to determine the relationship between retreatment of bCSDH and clinical, radiological, and surgical variables.

RESULTS

Two hundred ninety-one patients with bCSDH were identified, and 264 of them underwent unilateral (136 patients) or bilateral (128 patients) surgery. The overall retreatment rate was 21.6% (57 of 264 patients). Cases treated with unilateral surgery had twice the risk of retreatment compared with cases undergoing bilateral surgery (28.7% vs 14.1%, respectively, p = 0.002). In accordance with previous studies, the data also showed that a separated hematoma density and the absence of postoperative drainage were independent predictors of retreatment.

CONCLUSIONS

In bCSDHs bilateral surgical intervention significantly lowers the risk of retreatment compared with unilateral intervention and should be considered when choosing a surgical procedure.

Surgical Treatments for Chronic Subdural Hematomas: A Comprehensive Systematic Review

BACKGROUND

Chronic subdural hematomas (CSDHs) are common neurosurgical conditions among elderly patients.

OBJECTIVE

To perform a detailed critical appraisal of all randomized controlled trials (RCTs) of surgical treatments for chronic subdural hematomas and to quantify their intervention effects.

METHODS

We performed a broad search for all RCTs with no language or date restrictions, asked the authors for missing data, and applied the Cochrane methods.

RESULTS

A total of 24 RCTs involved 1900 patients and 15 comparisons. All outcomes of practical interest were analyzed. Postoperative drainage after burr-hole evacuation reduced the rate of recurrence (risk ratio 0.48, 95% confidence interval 0.34-0.66, P < 0.00001) with no other clear benefits or complications.

CONCLUSIONS

This comprehensive, best evidence-based, quantitative, systematic review indicates that the use of a closed system drainage after burr-hole evacuation reduces the rate of recurrences but has no other significant differences. The findings also suggest that: (1) treatment with twist drills is equivalent to that with burr holes; (2) the postoperative bed header in the elevated position might reduce the length of hospital stay; (3) irrigation of the subdural space with thrombin solution in patients with high risk of recurrence might reduce this risk; and (4) treatment with twist drill followed by a closed system drainage during 48 hours, instead of 96 hours, might reduce general complication rates. Most of the trials suffered from unclear or high risks of bias and many involved small samples, precluding strong and definitive conclusions.

Surgical treatment of 137 cases with chronic subdural hematoma at the university clinical center of Kosovo during the period 2008-2012

Background:

Chronic subdural hematoma (CSDH) is frequent pathology in neurosurgical practice. The aim of this study is to present the first series of patients with CSDH, who got surgically treated in Clinic of Neurosurgery, University Clinical Center of Kosovo.

Materials and Methods:

This is a retrospective study that included 137 patients with CSDH who had been treated during the period 2008–2012. The data were collected and analyzed from the archives and protocols of the University Clinical Center of Kosovo. Patients were analyzed in many aspects such as age, gender, etiological factors, clinical features, localization, diagnoses, methods of surgical interventions, recurrences and mortality of patients.

Results:

From 137 patients with CSDH, 106 (77.3%) were males and 31 (22.7%) females. Average age of patients was 62.85 years. Analyzed according to the decades, the highest number of causes with CSDH was between 70 and 79 years (46%). The head trauma has been responsible for CSDH in 88 patients (64.3%), while the main symptom was headache (92 patients or 67.1%). One burr-hole trepanation with closed drainage system has been used in majority of cases (in 101 patients or 73.7%). The recurrence of CSDH was 6.5%, whereas mortality 2.9%.

Conclusion:

CSDH is more common in elderly patients. The male-female ratio is 3.4:1. Like other authors we also think that treatment with one burr-hole and drainage is a method of choice, because of its simplicity and safety.

Subdural hematomas: an analysis of 1181 Kashmiri patients

BACKGROUND

We endeavored to analyze patients of subacute and chronic subdural hematomas studied in a 4-year period at the Sher-i-Kashmir Institute of Medical Sciences, Kashmir, India.

METHODS

The study was a retrospective analysis of 1181 patients of subdural hematomas. Demographic characteristics, clinico-radiologic features, operative modalities, and outcome were studied. Acute subdural hematomas were excluded from the study.

RESULTS

The mean age was 60.4 ± 12.4 and males outnumbered females. Chronic subdural collections were more common than subacute subdural hematomas and left side predominated. Two burr holes with closed-system drainage was used in most patients. Incidence of postoperative seizures is very low. Overall recurrence rates were low; however, multilocular hematomas had the highest incidence of recurrence. Morbidity and mortality were 7.53% and 2.96%, respectively. Preoperative neurologic grade correlated with outcome.

CONCLUSIONS

Subdural hematomas are common in elderly males. Preoperative neurologic grade dictates the outcome. Multilocular hematomas have a higher chance of recurrence. Craniotomy should be reserved for recurrent hematomas, and there may be a scope of craniotomy for multilocular chronic subdural hematomas at the outset. Antiepileptic prophylaxis is not routinely recommended.

What determines the laterality of the chronic subdural hematoma?

OBJECTIVE

Chronic subdural hematomas (CSDH) are more common on the left hemisphere than on the right. We verified this left predilection of CSDH and tried to explain the reason for this discrepancy.

METHODS

We investigated the laterality of CSDH in 182 patients who were treated from January 2005 to December 2009. We examined the symmetry of the cranium and the location of the lesion.

RESULTS

CSDH was more common on the left-side. The cranium was symmetric in 63 patients, asymmetric in 119 patients. The asymmetric crania were flat on the right-side in 77 patients, on the left-side in 42 patients. The density of the CSDHs was hypodense in 29 patients, isodense 132 patients, and the others in 21 patients. Bilateral hematomas were more common in the hypodense group. In the right flat crania, the hematoma was more commonly located on the opposite side of the flat side. While in the left flat crania, the hematoma was more common on the same side.

CONCLUSION

CSDHs occurred more frequently on the left side. The anatomical asymmetry of the cranium influences the left predilection of CSDH.