1
|
John K, Syed S, Kaestner T, Dashti R, Fiorella D, Sadasivan C. Liquid embolic surface area as a predictor of chronic subdural hematoma resolution in middle meningeal artery embolization. J Neurointerv Surg 2023:jnis-2023-021118. [PMID: 38050160 DOI: 10.1136/jnis-2023-021118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 11/17/2023] [Indexed: 12/06/2023]
Abstract
BACKGROUND Liquid embolic agents (LEAs) such as ethylene vinyl alcohol (EVOH) are utilized for middle meningeal artery embolization (MMAE) for chronic subdural hematomas (cSDH). LEAs may be advantageous for MMAE as they are permanent and can penetrate the microvasculature of the subdural membranes. LEA surface area (SA) can quantify this penetration. The segmentation of LEA SA is not described in the literature and may be of interest in refining MMAE technique. METHODS We retrospectively collected computerized tomography (CT) scans from 74 patients (with 95 cSDH) who underwent first-line MMAE with EVOH. Non-contrast head CTs were acquired pre-embolization, immediately post-embolization and at 1-, 3-, and 6 month follow-up. A 3D-Slicer was used to segment hematoma volumes and the liquid embolic cast. We hypothesized that greater LEA SA would be correlated with greater improvements in cSDH volumetric resolution. RESULTS There was significant resolution in cSDH volumes over the follow-up period compared to preoperative volume (p<0.0001). The LEA SA was significantly correlated with the rate of cSDH resolution at 3 months (R2=0.08, p=0.03), and 6 months (R2=0.14, p=0.01). CONCLUSIONS The correlation of LEA surface area with hematoma resolution at 3-months and 6-months suggests greater LEA penetration may improve radiographic outcomes. This study uniquely provides a quantitative radiological perspective on the effect of LEA penetration on cSDH resolution.
Collapse
Affiliation(s)
- Kevin John
- Department of Radiology, Stony Brook Medicine, Stony Brook, New York, USA
| | - Shoaib Syed
- Department of Neurological Surgery, Stony Brook Medicine, Stony Brook, New York, USA
| | | | - Reza Dashti
- Department of Neurological Surgery, Stony Brook Medicine, Stony Brook, New York, USA
| | - David Fiorella
- Department of Neurological Surgery, Stony Brook Medicine, Stony Brook, New York, USA
| | - Chander Sadasivan
- Department of Neurological Surgery, Stony Brook Medicine, Stony Brook, New York, USA
| |
Collapse
|
2
|
De Maria L, Chaurasia B, Agosti E, Garg K, Burkhardt JK, Goehre F, Borghei-Razavi H, Servadei F, Fontanella MM. Non-surgical management of chronic subdural hematoma: insights and future perspectives from an international survey including neurosurgeons from 90 countries worldwide. Int J Neurosci 2023:1-10. [PMID: 37982390 DOI: 10.1080/00207454.2023.2286202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 11/15/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Chronic subdural hematoma (cSDH) is one of the most common neurosurgical conditions. Although surgical evacuation is still the gold standard for treatment, recent advances have led to the development of other management strategies, such as medical therapies and endovascular middle meningeal artery (MMA) embolization. Through this international survey, we investigated the global trends in cSDH management, focusing on medical and endovascular treatments. DESIGN AND PARTICIPANTS A 14-question, web-based, anonymous survey was distributed to neurosurgeons worldwide. RESULTS Most responders do not perform MMA embolization (69.5%) unless for specific indications (29.6%). These indications include residual cSDH after surgical evacuation (58.9%) or cSDH in patients on antiplatelet medications to avoid surgical evacuation (44.8%). Survey participants from teaching versus non-teaching hospitals (p = 0.002), public versus private hospitals (p = 0.022), and Europe versus other continents (p < 0.001) are the most users of MMA embolization. A large number of participants (51%) declare they use a conservative/medical approach, mainly to avoid surgery in patients with small cSDH (74.8%). CONCLUSIONS This survey highlights the current trends of cSDH management, focusing on conservative and MMA embolization treatment strategies. Most responders prefer a conservative approach for patients with small cSDHs not requiring surgical evacuation. However, in higher-risk scenarios such as residual hematomas after surgery or patients on antiplatelet medications, MMA embolization is regarded as a reasonable option by participants. Future studies should clarify the indications of MMA embolization, including appropriate patient selection and efficacy as a stand-alone procedure.
Collapse
Affiliation(s)
| | | | | | - Kanwaljeet Garg
- Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Jan-Karl Burkhardt
- Neurosurgery, Hospital of the University of Pennysylvania, Philadelphia, PA, USA
| | - Felix Goehre
- Neurosurgery, Bergmannstrost Hospital Halle, Halle, Germany
| | | | - Franco Servadei
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- IRCCS Humanitas Research Hospital, Milan, Italy
| | | |
Collapse
|
3
|
Rodriguez B, Morgan I, Young T, Vlastos J, Williams T, Hrabarchuk EI, Tepper J, Baker T, Kellner CP, Bederson J, Rapoport BI. Surgical techniques for evacuation of chronic subdural hematoma: a mini-review. Front Neurol 2023; 14:1086645. [PMID: 37456631 PMCID: PMC10338715 DOI: 10.3389/fneur.2023.1086645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 05/30/2023] [Indexed: 07/18/2023] Open
Abstract
Chronic subdural hematoma is one of the most common neurosurgical pathologies with over 160,000 cases in the United States and Europe each year. The current standard of care involves surgically evacuating the hematoma through a cranial opening, however, varied patient risk profiles, a significant recurrence rate, and increasing financial burden have sparked innovation in the field. This mini-review provides a brief overview of currently used evacuation techniques, including emerging adjuncts such as endoscopic assistance and middle meningeal artery embolization. This review synthesizes the body of available evidence on efficacy and risk profiles for each critical aspect of surgical technique in cSDH evacuation and provides insight into trends in the field and promising new technologies.
Collapse
Affiliation(s)
- Benjamin Rodriguez
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
- Icahn School of Medicine, New York, NY, United States
| | - Isabella Morgan
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
| | - Tirone Young
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
- Icahn School of Medicine, New York, NY, United States
| | - Joseph Vlastos
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
- Icahn School of Medicine, New York, NY, United States
| | - Tyree Williams
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
- Rensselaer Polytechnic Institute, Troy, NY, United States
| | - Eugene I. Hrabarchuk
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
- Icahn School of Medicine, New York, NY, United States
| | - Jaden Tepper
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
| | - Turner Baker
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
| | - Christopher P. Kellner
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
- Icahn School of Medicine, New York, NY, United States
| | - Joshua Bederson
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
- Icahn School of Medicine, New York, NY, United States
| | - Benjamin I. Rapoport
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
- Icahn School of Medicine, New York, NY, United States
| |
Collapse
|
4
|
Jensen TSR, Binderup T, Olsen MH, Kjaer A, Fugleholm K. Subdural Levels of Interleukin 1-receptor Antagonist are Elevated in Patients with Recurrent Chronic Subdural Hematomas. Inflammation 2023:10.1007/s10753-023-01811-8. [PMID: 37039933 DOI: 10.1007/s10753-023-01811-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 03/20/2023] [Accepted: 03/27/2023] [Indexed: 04/12/2023]
Abstract
Anti-inflammatory treatment reduces the risk of recurrent chronic subdural hematoma (CSDH), but clinical implementation is improper due to side effects. Exact knowledge of subdural molecules involved in recurrent CSDH may lead to targeted medical treatment and possibly improve the prospect of a personalized approach by eliminating the broad use of anti-inflammatory drugs on the entire CSDH population. With this study, we aim to (1) describe the associations between cytokine levels at the primary surgery and the risk of subsequent recurrence and (2) describe the association between cytokines in patients with recurrent CSDH between the first and second operations. Systemic and subdural levels of pro- and anti-inflammatory cytokines were measured and compared between patients with the first-time CSDH and recurrent CSDH. Cytokine levels were analyzed using a multiplex antibody bead kit. In case of recurrent CSDH within 90 days of follow-up, the samples were re-collected and analyzed. We included 101 adult CSDH patients of which 20 had a recurrence. The levels of cytokines in the CSDH fluid from patients who were operated on for the first-time CSDH were not associated with the risk of later developing a recurrence. We found interleukin-1 receptor antagonist (IL-1ra) to be elevated in subdural fluid in patients with recurrent CSDH at the time of their second operation (p = 0.0005). This study provides knowledge on cytokine composition in the subdural fluid in patients with CSDH with and without recurrence. IL-1ra is elevated in subdural fluid in patients with recurrent CSDH at the time of the second operation, identifying a possible medical target.
Collapse
Affiliation(s)
- Thorbjørn Søren Rønn Jensen
- Department of Neurosurgery, The Neuroscience Centre, Copenhagen University Hospital, Inge Lehmanns Vej 6, 2100, Rigshospitalet, Copenhagen, Denmark.
| | - Tina Binderup
- Department of Clinical Physiology and Nuclear Medicine & Cluster for Molecular Imaging, Rigshospitalet & Department of Biomedical Sciences, Copenhagen University Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Markus Harboe Olsen
- Department of Neuroanaesthesiology, The Neuroscience Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Andreas Kjaer
- Department of Clinical Physiology and Nuclear Medicine & Cluster for Molecular Imaging, Rigshospitalet & Department of Biomedical Sciences, Copenhagen University Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Kåre Fugleholm
- Department of Neurosurgery, The Neuroscience Centre, Copenhagen University Hospital, Inge Lehmanns Vej 6, 2100, Rigshospitalet, Copenhagen, Denmark
| |
Collapse
|
5
|
Puccio DJ, Deng H, Eagle SR, Okonkwo DO, Nwachuku EL. Pilot Biomarker Analysis and Decision Tree Algorithm Modeling of Patients with Chronic Subdural Hematomas. Neurotrauma Rep 2023; 4:184-196. [PMID: 36974123 PMCID: PMC10039273 DOI: 10.1089/neur.2022.0062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2023] Open
Abstract
The elderly population are at high risk for developing chronic subdural hematoma (cSDH). Surgical evacuation of cSDH is one of the most common procedures performed in neurosurgery. The present study aims to identify potential inflammatory biomarkers associated with its development and recurrence. Patients (>65 years of age) who presented with symptomatic cSDH (≥1 cm thickness or ≥5 mm midline shift [MLS]), requiring surgical intervention, were prospectively enrolled. The collected cSDH fluid was analyzed for inflammatory markers. Computed tomography (CT) scan data included pre-operative cSDH thickness and MLS. Outcome data included Glasgow Outcome Scale-Extended (GOS-E) score at 3, 6, and 12 months post-surgery, as well as cSDH recurrence. A decision tree model was used to determine the predictive power of extracted analytes for MLS, cSDH thickness, and recurrence. This pilot study includes 20 enrolled patients (mean age 77.9 ± 7.4 years and 85% falls). Rate of cSDH recurrence was 42%, with 21% requiring reoperation. Chemokine (C-X-C motif) ligand 9 (CXCL9) concentrations correlated with cSDH thickness (r = 0.975, p = 0.040). Interleukin (IL)-6 and vascular endothelial growth factor (VEGF)-A concentrations correlated with MLS (r = 0.974, p = 0.005; r = 0.472, p = 0.036, respectively). IL-5 concentrations correlated with more favorable GOS-E scores at 3, 6, and 12 months (r = 0.639, p = 0.006; r = 0.727, p = 0.003; r = 0.693, p = 0.026, respectively). Regulated on activation, normal T-cell expressed and secreted (RANTES) concentrations correlated with complete cSDH resolution (r = 0.514, p = 0.021). The decision tree model identified that higher concentrations of CXCL9 were predictive of MLS (risk ratio [RR] = 12.0), higher concentrations of IL-5 were predictive of cSDH thickness (RR = 4.5), and lower concentrations of RANTES were predictive of cSDH recurrence (RR = 2.2). CXCL9, IL-6, VEGF, IL-5, and RANTES are associated with recurrence after surgery and may be potential biomarkers for predicting cSDH recurrence and neurological outcomes.
Collapse
Affiliation(s)
- David J. Puccio
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Address correspondence to: David J. Puccio, BS, Department of Neurological Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street, Suite B-400, Pittsburgh, PA 15213, USA.
| | - Hansen Deng
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Shawn R. Eagle
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - David O. Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Enyinna L. Nwachuku
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
6
|
Karibe H, Narisawa A, Nagai A, Yamanouchi S, Kameyama M, Nakagawa A, Tominaga T. Incidence of Chronic Subdural Hematoma after Mild Head Trauma in Elderly Patients with or without Pre-traumatic Conditioning of Anti-thrombotic Drugs. Neurol Med Chir (Tokyo) 2023; 63:91-96. [PMID: 36682795 PMCID: PMC10072887 DOI: 10.2176/jns-nmc.2022-0327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Anti-thrombotic drugs may increase the risk for chronic subdural hematoma (CSDH). However, whether to continue or discontinue/counteract these drugs has not been investigated in patients with mild head trauma. CSDH incidence after mild head trauma, as well as the risk for CSDH in patients with anti-thrombotic drugs, were investigated in this study. The study included 765 consecutive elderly (>65 y.o.) patients with mild head trauma and an initial Glasgow Coma Scale (GCS) score of 14 or 15. All patients received initial CT within 24 hours after trauma and were re-examined 30 days after trauma to detect CSDH formation, repeating for every 30 days to examine symptomatic CSDH progression. Patients were divided into two groups, with anti-thrombotic drugs (n = 195) or without them (n = 263), to investigate the influence of pre-traumatic conditioning with anti-thrombotic drugs on CSDH. The whole sample was 458 out of 765 cases. The incidence of CSDH formation was 91 out of 458 cases (19.9%) after mild head trauma, with no significant difference between with and without anti-thrombotic drugs. CSDH progressed as symptomatic in 21 out of 458 cases (4.6%), with no significant difference between with and without anti-thrombotic drugs. Pre-traumatic conditioning with anti-thrombotic drugs and its continuation after trauma did not affect the incidence of formation or symptomatic progression of CSDH. This finding suggests that discontinuing and/or counteracting anti-thrombotic drugs may be unnecessary in patients with mild head trauma.
Collapse
Affiliation(s)
| | | | - Arata Nagai
- Department of Neurosurgery, Sendai City Hospital
- Department of Neurosurgery, Tohoku University Graduate School of Medicine
| | | | | | - Atsuhiro Nakagawa
- Department of Neurosurgery, Tohoku University Graduate School of Medicine
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine
| |
Collapse
|
7
|
Zhu B, Yu X, Ou Y, Guo X, Liu W, Wu L. Nutritional and inflammatory peripheral blood markers for risk assessment of chronic subdural hematoma: a case-control study. Clin Neurol Neurosurg 2023; 227:107640. [PMID: 36870089 DOI: 10.1016/j.clineuro.2023.107640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 02/09/2023] [Accepted: 02/18/2023] [Indexed: 03/06/2023]
Abstract
BACKGROUND Some peripheral blood markers have been demonstrated to be correlated with the re-formation of chronic subdural hematoma (CSDH). The aim of this study was to identify the correlation between nutritional/inflammatory peripheral blood markers and CSDH. METHODS 188 CSDH patients and 188 age-matched healthy controls were included in this research. The clinical characteristics and peripheral blood markers associated with nutritional or inflammatory status were obtained and analyzed. Conditional logistic regression analysis was applied to identify the potential CSDH risk factors. All the participants were divided into 3 groups based on the tertiles of change in risk factors. The Cochran-Armitage test and one way ANOVA were applied to identify the association between baseline characteristics and independent risk factors. Moreover, the net reclassification index (NRI) and integrated discrimination index (IDI) were calculated to evaluate the improvement in model performance after adding the independent risk factors in the conventional model. RESULTS The logistic regression analysis demonstrated that the increased albumin (OR, 0.615; 95 %CI,0.489-0.773; P < 0.001) and lymphocyte count (OR, 0.141; 95 %CI,0.025-0.796; P = 0.027) were associated with lower risk of CSDH. Moreover, addition of albumin and lymphocyte to conventional risk factors significantly improved the risk prediction of CSDH(NRI: 46.47 %, P < 0.001; IDI: 30.92 %, P < 0.001; NRI: 22.45 %, P = 0.027; IDI: 1.23 %, P = 0.037, respectively) CONCLUSION: The decreased albumin and lymphocyte levels were correlated with a high risk of chronic subdural hematoma. The nutritional and inflammatory serum markers should be put great attention because these markers may play roles in finding the cause of CSDH and predicting its risk.
Collapse
Affiliation(s)
- Bingcheng Zhu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaofan Yu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yunwei Ou
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xufei Guo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Weiming Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Neurological Center, People's Hospital of Ningxia Hui Autonomous Region, Yinchuan, China.
| | - Liang Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
| |
Collapse
|
8
|
Pedicelli A, Valente I, Alexandre A, Scarcia L, Gigli R, Signorelli F, Visocchi M. Middle Meningeal Artery Embolization for the Management of Chronic Subdural Hematomas: A New-Old Treatment. ACTA NEUROCHIRURGICA. SUPPLEMENT 2023; 135:115-118. [PMID: 38153458 DOI: 10.1007/978-3-031-36084-8_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
Chronic subdural hematoma (cSDH) is defined as a subdural collection of blood on CT imaging that tends to persist and gradually increase in volume over time, with components that are hypodense or isodense compared to the brain. There are no proven guidelines for the management of patients with cSDH. Surgical approaches included burr hole, twist drill hole, and craniotomy-based evacuations. Outcomes after surgical removal is generally favorable, but cSDH tends to recur after the initial evacuation.Middle meningeal artery (MMA) embolization has been gaining increasing popularity among the treatments of cSDH. This is largely due to a growing population of patients with cSDH who are refractory to other treatments or in patients who present with multiple comorbidities or who are taking antiplatelet and anticoagulant medications. The goal of middle meningeal artery (MMA) embolization is to devascularize subdural membranes associated with SDH so that the balance between continued leakage and reabsorption is shifted toward reabsorption.We discuss our clinical and technical approach to cSDH treated with perioperative embolization of the MMA.
Collapse
Affiliation(s)
- A Pedicelli
- Dipartimento di Diagnostica per immagini, Radioterapia, Oncologia ed Ematologia, Fondazione Policlinico Universitario A.Gemelli IRCCS, Rome, Italy
| | - I Valente
- Dipartimento di Diagnostica per immagini, Radioterapia, Oncologia ed Ematologia, Fondazione Policlinico Universitario A.Gemelli IRCCS, Rome, Italy.
| | - A Alexandre
- Dipartimento di Diagnostica per immagini, Radioterapia, Oncologia ed Ematologia, Fondazione Policlinico Universitario A.Gemelli IRCCS, Rome, Italy
| | - L Scarcia
- Università Cattolica del Sacro Cuore, sede di Roma, Rome, Italy
| | - R Gigli
- Università Cattolica del Sacro Cuore, sede di Roma, Rome, Italy
| | - Francesco Signorelli
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Massimiliano Visocchi
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Institute of Neurosurgery, Catholic University of Rome, Rome, Italy
| |
Collapse
|
9
|
OTSUJI R, AMANO T, MATSUO S, MIYAMATSU Y, HARA K, TOKUNAGA S, NAKAMIZO A. Chronic Subdural Hematoma after Craniotomy with Preoperative Embolization of Middle Meningeal Artery: A Case Report. NMC Case Rep J 2022; 9:151-155. [PMID: 35836492 PMCID: PMC9239696 DOI: 10.2176/jns-nmc.2022-0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 03/22/2022] [Indexed: 11/20/2022] Open
Abstract
Endovascular embolization of the middle meningeal artery (MMA) has been reported as an effective method for treating chronic subdural hematoma (CSDH); however, its preventive effect on CSDH following craniotomy is unknown. We present a case in which MMA embolization was ineffective in preventing CSDH following craniotomy. A 56-year-old man who complained of diplopia was diagnosed with sphenoid ridge meningioma with a 3-cm diameter. MMA embolization prior to the operation and total surgical removal of the tumor were performed. Two months postoperatively, the patient complained of headache and hemiparesis of the left side. CSDH with a 15-mm thickness and a midline shift was observed. MMA embolization before inflammation may not play a role in preventing CSDH development because MMA embolization is considered effective in CSDH because it is associated with the blood supply of neovessels that are newly formed due to inflammation. Therefore, MMA embolization might not be effective in preventing the occurrence of CSDH following craniotomy.
Collapse
Affiliation(s)
- Ryosuke OTSUJI
- Department of Neurosurgery, National Hospital Organization Kyushu Medical Center, Clinical Research Institute
| | - Toshiyuki AMANO
- Department of Neurosurgery, National Hospital Organization Kyushu Medical Center, Clinical Research Institute
| | - Satoshi MATSUO
- Department of Neurosurgery, National Hospital Organization Kyushu Medical Center, Clinical Research Institute
| | - Yuichiro MIYAMATSU
- Department of Neurosurgery, National Hospital Organization Kyushu Medical Center, Clinical Research Institute
| | - Kenta HARA
- Department of Neuroendovascular Surgery, National Hospital Organization Kyushu Medical Center, Clinical Research Institute
| | - So TOKUNAGA
- Department of Neuroendovascular Surgery, National Hospital Organization Kyushu Medical Center, Clinical Research Institute
| | - Akira NAKAMIZO
- Department of Neurosurgery, National Hospital Organization Kyushu Medical Center, Clinical Research Institute
| |
Collapse
|
10
|
Vychopen M, Güresir E, Wach J. Anti-Inflammatory Drug Therapy in Chronic Subdural Hematoma: A Systematic Review and Meta-Analysis of Prospective Randomized, Double-Blind and Placebo-Controlled Trials. Int J Mol Sci 2022; 23:ijms232416198. [PMID: 36555838 PMCID: PMC9784956 DOI: 10.3390/ijms232416198] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 12/12/2022] [Accepted: 12/16/2022] [Indexed: 12/23/2022] Open
Abstract
Althoughanti-inflammatory drug therapy has been identified as potentially beneficial for patients suffering from chronic subdural hematoma (cSDH), contemporary literature presents contradictory results. In this meta-analysis, we aimed to investigate the impact of anti-inflammatory drug therapy on mortality and outcome. We searched for eligible randomized, placebo-controlled prospective trials (RTCs) on PubMed, Embase and Medline until July 2022. From 97 initially identified articles, five RTCs met the criteria and were included in our meta-analysis. Our results illustrate significantly lower rates of recurrent cSDH (OR: 0.35; 95% CI: 0.21-0.58, p = 0.0001) in patients undergoing anti-inflammatory therapy. In the subgroup of patients undergoing primary conservative treatment, anti-inflammatory therapy was associated with lower rates of "switch to surgery" cases (OR: 0.30; 95% CI: 0.14-0.63, p = 0.002). Despite these findings, anti-inflammatory drugs seemed to be associated with higher mortality rates in patients undergoing surgery (OR: 1.76; 95% CI: 1.03-3.01, p = 0.04), although in the case of primary conservative treatment, no effect on mortality has been observed (OR: 2.45; 95% CI: 0.35-17.15, p = 0.37). Further multicentric prospective randomized trials are needed to evaluate anti-inflammatory drugs as potentially suitable therapy for asymptomatic patients with cSDH to avoid the necessity of surgical hematoma evacuation on what are predominantly elderly, vulnerable, patients.
Collapse
|
11
|
Edlmann E, Giorgi-Coll S, Thelin EP, Hutchinson PJ, Carpenter KLH. Dexamethasone reduces vascular endothelial growth factor in comparison to placebo in post-operative chronic subdural hematoma samples: A target for future drug therapy? Front Neurol 2022; 13:952308. [PMID: 36158966 PMCID: PMC9492873 DOI: 10.3389/fneur.2022.952308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 07/25/2022] [Indexed: 11/30/2022] Open
Abstract
Background Chronic subdural hematoma (CSDH) is a collection of blood and fluid that arises on the brain surface due to a combination of trauma and/or inflammation. The mainstay of treatment is surgical drainage, but CSDH can recur. Dexamethasone has been shown to reduce CSDH recurrence, but its mechanism of action has not been fully elucidated. Understanding the inflammatory mediators driving CSDH formation and recurrence and how dexamethasone alters this can help develop new therapeutic strategies. Methods A subgroup of adult patients recruited to the Dex-CSDH trial, randomized to dexamethasone or placebo, who had surgery for their CSDH, were included. CSDH fluid and peripheral blood were collected intraoperatively, from post-operative drains and operated recurrences. Samples were analyzed using a 12-plex panel of inflammatory mediators. Clinical patient data were also reviewed. Results A total of 52 patients, with a mean age of 76 years, were included. Five recurrent CSDHs occurred. Vascular endothelial growth factor (VEGF) had the highest concentration across all CSDHs, and only matrix metalloproteinase (MMP)-9 had lower concentrations in CSDH compared to plasma but was increased in recurrent CSDHs. The interleukin (IL)-10 concentration was significantly lower in primary CSDHs that recurred. Most inflammatory mediators increased post-operatively, and dexamethasone significantly reduced the post-operative peak in VEGF on day 2, compared to placebo. Conclusion It is evident that VEGF plays a critical role in the inflammatory response in CSDH. The post-operative reduction with dexamethasone could signal the mechanism by which it reduces recurrence. Novel therapies with a better side-effect profile than dexamethasone should be targeted at VEGF or potential alternatives such as IL-10 supplementation.
Collapse
Affiliation(s)
- Ellie Edlmann
- Peninsula Medical School, Faculty of Health, University of Plymouth, Plymouth, United Kingdom
- Southwest Neurosurgical Centre, Derriford Hospital, Plymouth, United Kingdom
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Susan Giorgi-Coll
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Eric P. Thelin
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Peter J. Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Keri L. H. Carpenter
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| |
Collapse
|
12
|
Weigel R, Schilling L, Krauss JK. The pathophysiology of chronic subdural hematoma revisited: emphasis on aging processes as key factor. GeroScience 2022; 44:1353-1371. [DOI: 10.1007/s11357-022-00570-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 04/07/2022] [Indexed: 12/24/2022] Open
|
13
|
Colamaria A, Sacco M, Iodice S, Fochi NP, Carbone F. Cerebrospinal fluid leak as a driving factor in chronic subdural hematoma formation: A histological study. Surg Neurol Int 2021; 12:578. [PMID: 34877064 PMCID: PMC8645496 DOI: 10.25259/sni_950_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 10/27/2021] [Indexed: 11/20/2022] Open
Abstract
Background: Chronic subdural hematoma (CSDH) represents the most common neurosurgical disease. Given the demographic shift toward an aging population, the overall incidence of this condition is increasing. Nevertheless, clarity in the pathophysiological process is yet to be made. Several etiological mechanisms have been proposed to initiate and consequently promote fluid collection in the subdural space. Traumatic injury of the bridging veins has long been considered the primum movens of the pathology but increasing evidence shows that trauma is not the only factor involved. Along with recent advances we sought to understand the role of the cerebrospinal fluid (CSF) in the buildup of the intense inflammatory reaction that characterizes CSDH. Methods: In the present study, we examined histological features of reactive membranes secondary to extracranial CSF leakage with CSDH-related membranes. Similarity and differences between the specimens were examined by means of light microscopy. Results: Histological similarities were consistently found between CSDH membranes and reactive membranes secondary to CSF leakage in the extracranial space. Activated histiocytes were highlighted in all specimens along with an intense inflammatory reaction. Conclusion: CSDH is most likely the result of a complex interaction among different pathophysiological events resulting from both traumatic and inflammatory etiologies. In the present work, we highlight how CSF leakage could be an early factor that leads to a cascade of events that culminates in CSDH formation.
Collapse
Affiliation(s)
| | - Matteo Sacco
- Department of Neurosurgery, "Riuniti" Hospital, Foggia, Italy
| | - Savino Iodice
- Department of Neurosurgery, "Riuniti" Hospital, Foggia, Italy
| | - Nicola Pio Fochi
- Department of Neurosurgery, University of Foggia, Foggia, Puglia, Italy
| | - Francesco Carbone
- Department of Neurosurgery, University of Foggia, Foggia, Puglia, Italy
| |
Collapse
|
14
|
Dicpinigaitis AJ, Al-Mufti F, Cooper JB, Faraz Kazim S, Couldwell WT, Schmidt MH, Gandhi CD, Cole CD, Bowers CA. Nationwide trends in middle meningeal artery embolization for treatment of chronic subdural hematoma: A population-based analysis of utilization and short-term outcomes. J Clin Neurosci 2021; 94:70-75. [PMID: 34863465 DOI: 10.1016/j.jocn.2021.10.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 09/29/2021] [Accepted: 10/03/2021] [Indexed: 11/29/2022]
Abstract
Middle meningeal artery (MMA) embolization represents a promising novel treatment modality for chronic subdural hematoma (cSDH), yet utilization and efficacy data are limited. This study evaluates the utilization and short-term outcomes of MMA embolization for cSDH treatment in a large national inpatient registry. cSDH patients treated with MMA embolization and/or surgical evacuation (craniotomy/burr hole drainage) were identified using the National Inpatient Sample (NIS) during 2012-2018 period. Temporal trends, complications, and discharge disposition were evaluated, and propensity score matching was implemented for adjusted comparisons and to mitigate confounding by indication. Among 60,045 cSDH patients identified, 390 (0.6%) underwent MMA embolization. Embolized patients presented more with high acute illness severity subclasses in comparison with surgically evacuated patients (53% vs. 34%, p = 0.004) yet did not experience any procedure-related hemorrhagic or ischemic complications. Although discharge disposition did not differ from those surgically managed, embolized patients had longer mean hospital stays (13 vs. 8 days, p = 0.023) and accrued greater hospital charges (p < 0.001). Following propensity adjustment, length of stay and charges remained greater in the embolization cohort, yet rates of routine discharge increased appreciably (40% vs. 30%, p = 0.141) relative to surgically treated cSDH patients. The utilization of embolization increased exponentially after 2015, reaching an apex in 2018 (3.7% of treated cSDH). This population-based national assessment demonstrates exponential increases in utilization of MMA embolization for cSDH treatment in recent years. Embolized patients had uncomplicated clinical courses and similar discharge dispositions as surgical evacuation patients. Large-scale prospective trials are warranted to further assess the efficacy of this modality.
Collapse
Affiliation(s)
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Jared B Cooper
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Syed Faraz Kazim
- Depertment of Neurosurgery, University of New Mexico, Albuquerque, NM, USA
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Meic H Schmidt
- Depertment of Neurosurgery, University of New Mexico, Albuquerque, NM, USA
| | - Chirag D Gandhi
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Chad D Cole
- Depertment of Neurosurgery, University of New Mexico, Albuquerque, NM, USA
| | - Christian A Bowers
- Depertment of Neurosurgery, University of New Mexico, Albuquerque, NM, USA.
| |
Collapse
|
15
|
Gong Z, Zhan D, Nie M, Li X, Gao C, Liu X, Xiang T, Yuan J, Jiang W, Huang J, Quan W, Wang D, Tian Y, Yuan H, Zhang J, Jiang R. Dexamethasone enhances the efficacy of atorvastatin in inhibiting excessively inflammation-induced abnormal angiogenesis by regulating macrophages. J Neuroinflammation 2021; 18:203. [PMID: 34526068 PMCID: PMC8444603 DOI: 10.1186/s12974-021-02257-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 08/27/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We have recently showed that atorvastatin (ATO) combined with low dose of dexamethasone (DEX) was more efficacious in treating patients with chronic subdural haematoma (CSDH) than ATO monotherapy. This study was designed to investigate the underlying mechanisms of the improved efficacy of this combined therapy. METHODS Mass spectrometry was performed to quantitatively detect drugs in haematoma fluids and serum samples from CSDH patients and also in cultured macrophages after treatment with either ATO alone or in combination with DEX. The differentiation and apoptosis of macrophages were evaluated using flow cytometry. The expression of cytokines, chemokines and angiogenesis-related proteins was evaluated using proteome profile arrays, immunoblots and ELISA, respectively. RESULTS ATO was detected in haematoma fluids and serum samples, whose levels were increased significantly in samples collected from patients treated with both ATO and DEX. ATO was also increased in cultured macrophages treated with ATO and DEX. The numbers of M1-polarized macrophages were higher than the M2 phenotype in the haematoma fluids of patients. Cultured macrophages treated with ATO and DEX had reduced numbers of M1-polarized macrophages, increased numbers of M2-polarized macrophages as compared to monotherapies, and decreased rate of apoptosis induced by high-dose DEX. DEX enhanced the anti-inflammatory and anti-angiogenic activity of ATO by suppressing VEGFA and other inflammatory angiogenic factors. Consistent with the finding, patients responded well to the drug treatments had lower serum levels of VEGFA. CONCLUSIONS We have shown for the first time that ATO given orally was detected in CSDH haematoma fluids. DEX enhances the anti-inflammatory and anti-angiogenic effects of ATO, primarily by increasing the presence of ATO in haematoma and macrophages and by regulating the functions of macrophages.
Collapse
Affiliation(s)
- Zhitao Gong
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, 300052, China.,Tianjin Neurological Institute, Key Laboratory of Post-neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China.,Department of Rehabilitation Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Daqiang Zhan
- Department of Pharmacy, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, China.,Department of pharmacy, Second Affiliated Hospital of Hainan Medical University, Hainan, China
| | - Meng Nie
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, 300052, China.,Tianjin Neurological Institute, Key Laboratory of Post-neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Xiaochun Li
- Tianjin Neurological Institute, Key Laboratory of Post-neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China.,Department of Pharmacy, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, China
| | - Chuang Gao
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, 300052, China.,Tianjin Neurological Institute, Key Laboratory of Post-neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Xuanhui Liu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, 300052, China.,Tianjin Neurological Institute, Key Laboratory of Post-neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Tangtang Xiang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, 300052, China.,Tianjin Neurological Institute, Key Laboratory of Post-neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Jiangyuan Yuan
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, 300052, China.,Tianjin Neurological Institute, Key Laboratory of Post-neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Weiwei Jiang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, 300052, China.,Tianjin Neurological Institute, Key Laboratory of Post-neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Jinhao Huang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, 300052, China.,Tianjin Neurological Institute, Key Laboratory of Post-neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Wei Quan
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, 300052, China.,Tianjin Neurological Institute, Key Laboratory of Post-neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Dong Wang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, 300052, China.,Tianjin Neurological Institute, Key Laboratory of Post-neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Ye Tian
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, 300052, China.,Tianjin Neurological Institute, Key Laboratory of Post-neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Hengjie Yuan
- Tianjin Neurological Institute, Key Laboratory of Post-neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China. .,Department of Pharmacy, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, China.
| | - Jianning Zhang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, 300052, China. .,Tianjin Neurological Institute, Key Laboratory of Post-neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China.
| | - Rongcai Jiang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, 300052, China. .,Tianjin Neurological Institute, Key Laboratory of Post-neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China.
| |
Collapse
|
16
|
Schwarz J, Carnevale JA, Goldberg JL, Ramos AD, Link TW, Knopman J. Perioperative prophylactic middle meningeal artery embolization for chronic subdural hematoma: a series of 44 cases. J Neurosurg 2021; 135:1627-1635. [PMID: 34020417 DOI: 10.3171/2020.10.jns202856] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 10/12/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Chronic subdural hematoma (cSDH) is a common and challenging pathology to treat due to both the historically high recurrence rate following surgical evacuation and the medical comorbidities inherent in the aging patient population that it primarily affects. Middle meningeal artery (MMA) embolization has shown promise in the treatment of cSDHs, most convincingly to avoid surgical evacuation in relatively asymptomatic patients. Symptomatic patients requiring surgical evacuation may also benefit from perioperative MMA embolization to prevent cSDH recurrence. The goal of this study was to determine the utility of perioperative MMA embolization for symptomatic cSDH requiring surgical evacuation and to assess if there is a decrease in the cSDH recurrence rate compared to historical recurrence rates following surgical evacuation alone. METHODS Symptomatic cSDHs were evacuated using a subdural evacuating port system (SEPS) with 5-mm twist-drill craniostomy in an intensive care unit or by performing a craniotomy in the operating room, using either a small (silver dollar, < 4 cm) or large (≥ 4 cm) craniotomy. MMA embolization was performed perioperatively using angiography, selective catheterization of the MMA, and infusion of polyvinyl particles. Outcomes were assessed clinically and radiographically with interval head CT imaging. RESULTS There were 44 symptomatic cSDHs in 41 patients, with 3 patients presenting with bilateral symptomatic cSDH. All cSDHs were evacuated using an SEPS (n = 18), a silver-dollar craniotomy (n = 16), or a large craniotomy (n = 10). Prophylactic MMA embolization was performed successfully in all cSDHs soon after surgical evacuation. There were no deaths and no procedural complications. There was an overall reduction of greater than 50% or resolution of cSDH in 40/44 (90.9%) cases, regardless of the evacuation procedure used. Of the 44 prophylactic cases, there were 2 (4.5%) cases of cSDH recurrence that required repeat surgical evacuation at the 1-year follow-up. These 2 cSDHs were initially evacuated using an SEPS and subsequently required a craniotomy, thereby representing an overall 4.5% recurrence rate of treated cSDH requiring repeat evacuation. Most notably, of the 26 patients who underwent surgical evacuation with a craniotomy followed by MMA embolization, none had cSDH recurrence requiring repeat intervention. CONCLUSIONS Perioperative prophylactic MMA embolization in the setting of surgical evacuation, via either craniotomy or SEPS, may help to lower the recurrence rate of cSDH.
Collapse
|
17
|
Xu X, Wang D, Han Z, Wang B, Gao W, Fan Y, Li F, Zhou Z, Gao C, Xiong J, Zhou S, Zhang S, Yang G, Jiang R, Zhang J. A novel rat model of chronic subdural hematoma: Induction of inflammation and angiogenesis in the subdural space mimicking human-like features of progressively expanding hematoma. Brain Res Bull 2021; 172:108-119. [PMID: 33932488 DOI: 10.1016/j.brainresbull.2021.04.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 04/23/2021] [Accepted: 04/24/2021] [Indexed: 12/11/2022]
Abstract
Pathophysiological mechanisms of chronic subdural hematoma (CSDH) involve localized inflammation, angiogenesis, and dysregulated coagulation and fibrinolysis. The scarcity of reproducible and clinically relevant animal models of CSDH hinders further understanding the underlying pathophysiology and improving new treatment strategies. Here, we developed a novel rat model of CSDH using extracellular matrices (Matrigel) and brain microvascular endothelial cell line (bEnd.3 cells). One hundred-microliter of Matrigel-bEnd.3 cell (106 cells per milliliter) mixtures were injected into the virtual subdural space of elderly male Sprague-Dawley rats. This approach for the first time led to a spontaneous and expanding subdural hematoma, encapsulated by internal and external neomembranes, formed as early as 3 d, reached its peak at 7 d, and lasted for more than 14 d, mimicking the progressive hemorrhage observed in patients with CSDH. The external neomembrane and hematoma fluid involved numerous inflammatory cells, fibroblasts, and highly fragile neovessels. Furthermore, a localized pathophysiological process was validated as evidenced by the increased expressions of inflammatory and angiogenic mediators in external neomembrane and hematoma fluid rather than in peripheral blood. Notably, the specific expression profiles of these mediators were closely associated with the dynamic changes in hematoma volume and neurological outcome. In summary, the CSDH model described here replicated the characteristics of human CSDH, and might serve as an ideal translational platform for preclinical studies. Meanwhile, the crucial roles of angiogenesis and inflammation in CSDH formation were reaffirmed.
Collapse
Affiliation(s)
- Xin Xu
- Department of Neurosurgery, Tianjin Medical University General Hospital, 154 Anshan Road, Tianjin, 300052, China; Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, 154 Anshan Road, Tianjin, 300052, China; Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Beijing, 100053, China
| | - Dong Wang
- Department of Neurosurgery, Tianjin Medical University General Hospital, 154 Anshan Road, Tianjin, 300052, China; Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, 154 Anshan Road, Tianjin, 300052, China
| | - Zhenying Han
- Department of Neurosurgery, Tianjin Medical University General Hospital, 154 Anshan Road, Tianjin, 300052, China; Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, 154 Anshan Road, Tianjin, 300052, China
| | - Bo Wang
- Department of Neurosurgery, Tianjin Medical University General Hospital, 154 Anshan Road, Tianjin, 300052, China; Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, 154 Anshan Road, Tianjin, 300052, China
| | - Weiwei Gao
- Department of Neurology, Tianjin Huanhu Hospital, 6 Jizhao Road, Tianjin, 300350, China
| | - Yueshan Fan
- Department of Neurosurgery, Tianjin Medical University General Hospital, 154 Anshan Road, Tianjin, 300052, China; Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, 154 Anshan Road, Tianjin, 300052, China
| | - Fanjian Li
- Department of Neurosurgery, Tianjin Medical University General Hospital, 154 Anshan Road, Tianjin, 300052, China; Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, 154 Anshan Road, Tianjin, 300052, China
| | - Ziwei Zhou
- Department of Neurosurgery, Tianjin Medical University General Hospital, 154 Anshan Road, Tianjin, 300052, China; Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, 154 Anshan Road, Tianjin, 300052, China
| | - Chuang Gao
- Department of Neurosurgery, Tianjin Medical University General Hospital, 154 Anshan Road, Tianjin, 300052, China; Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, 154 Anshan Road, Tianjin, 300052, China
| | - Jianhua Xiong
- Department of Neurosurgery, Tianjin Medical University General Hospital, 154 Anshan Road, Tianjin, 300052, China; Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, 154 Anshan Road, Tianjin, 300052, China
| | - Shuai Zhou
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, 154 Anshan Road, Tianjin, 300052, China
| | - Shu Zhang
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, 154 Anshan Road, Tianjin, 300052, China
| | - Guili Yang
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, 154 Anshan Road, Tianjin, 300052, China
| | - Rongcai Jiang
- Department of Neurosurgery, Tianjin Medical University General Hospital, 154 Anshan Road, Tianjin, 300052, China; Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, 154 Anshan Road, Tianjin, 300052, China.
| | - Jianning Zhang
- Department of Neurosurgery, Tianjin Medical University General Hospital, 154 Anshan Road, Tianjin, 300052, China; Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, 154 Anshan Road, Tianjin, 300052, China.
| |
Collapse
|
18
|
Impact of inflammatory cell ratio, biomarkers, activated partial thromboplastin time and prothrombin time on chronic subdural haematoma severity and outcome. Eur J Trauma Emerg Surg 2021; 48:1085-1092. [PMID: 33839805 DOI: 10.1007/s00068-021-01665-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 03/30/2021] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Chronic subdural haematoma (CSH) has multifactorial mechanisms involved in its development and progression. Identifying readily available inflammatory and coagulation indices that can predict the prognosis of CSH will help in clinical care, prognosis, generating objective criteria for assessing efficacy of treatment strategies and comparisons of treatment efficacy between clinical studies. We conducted a study in which we evaluated the impact value of neutrophil to lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), inflammatory biomarkers (erythrocyte sedimentation rate and C-reactive protein), activated partial thromboplastin time (APTT), prothrombin time (PT) and international normalized ratio (INR) at presentation on CSH severity and outcome using Glasgow outcome scale (GOS), Markwalder grading scale (MGS) and Lagos brain disability examination scale (LABDES). METHODS We prospectively studied patients in a single healthcare system with clinical and radiological features of chronic subdural haematoma. Only patients who were managed surgically were recruited. The primary outcome was predictors of severe form CSH (using admission Glasgow coma scale score, MGS grade, inflammatory cells and biomarkers, APTT, PT, and INR) and outcome (using GOS, MGS and LABDES grades 3 months) with secondary outcome being mortality rate, 3 months following surgery. Good outcome was defined as GOS score > 3, LABDES score ≥ 40 at three months and MGS score < 2. Differences in categorical and continuous variables between groups were compared using Fisher's exact test or Chi-square test (χ2) analysis, one-way ANOVA or Kruskal-Wallis test (in case of non-normal distribution). RESULTS We included 61 patients with a male-to-female ratio of 2.6:1 and mean age of 57.5 ± 13.3 years (median 58 years; 27-83 years). The pre-op MGS grade was significantly associated with the LABDES (p = 0.034), GOS (p = 0.011) and post-op MGS (p = 0.007) grade. All the patients that died had elevated APTT and PT with low PLR. A low admission PLR was significantly associated with a poor outcome using the GOS (p = 0.001), MGS (p = 0.011) and LABDES grade (p = 0.006) (Table 3). A high APTT was also significantly associated with a worse outcome using GOS (p = 0.007), MGS (p = 0.007) and LABDES grade (p = 0.003). There were three (4.9%) deaths with post-mortem diagnosis of pulmonary embolism, chronic renal failure and irreversible craniocaudal herniation syndrome. All the patients that died had elevated APTT and PT with low PLR. CONCLUSION Patients' admission APTT, PT, INR and PLR are good predictors of outcome using the GOS. A high admission INR is also associated with a worse outcome using MGS and LABDES grade.
Collapse
|
19
|
Takei J, Tanaka T, Yamamoto Y, Hatano K, Ichinose D, Maruyama F, Tochigi S, Hasegawa Y, Murayama Y. Significantly high concentrations of vascular endothelial growth factor in chronic subdural hematoma with trabecular formation. Clin Neurol Neurosurg 2021; 202:106458. [PMID: 33545457 DOI: 10.1016/j.clineuro.2020.106458] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 12/25/2020] [Accepted: 12/26/2020] [Indexed: 10/22/2022]
Abstract
The underlying mechanism of chronic subdural hematoma (CSDH) after minor head injury is complex, probably due to mechanical injury of the arachnoid membrane, hematological coagulopathy, and pathological angiogenesis in the dura caused by inflammatory cytokines including vascular endothelial growth factor (VEGF). To confirm whether VEGF might be a reliable predictive biomarker for the natural history of CSDH, including progression and recurrence, we analyzed the correlation of VEGF concentration in the subdural fluid with CT findings and clinical features, including interval from minor head injury. Based on CT classification by hematoma density, the mean concentration of VEGF in hematoma fluid was found to be highest in the trabecular group, whereas the recurrence of CSDH was most frequent in the separated group in which VEGF concentration was low. There was a significant correlation between VEGF concentration and the CT classification. Furthermore, only in the trabecular group, a significant negative correlation between the VEGF concentration and interval from minor head injury to surgery was observed. These results suggest that VEGF concentration in the hematoma alone could not be a reliable predictive biomarker for the natural history of CSDH including its recurrence. Amongst the classified groups of CSDH, the trabecular group is likely to follow a different time course of VEGF concentration in the hematoma fluid compared to the other three groups.
Collapse
Affiliation(s)
- Jun Takei
- Department of Neurosurgery, Jikei University School of Medicine Kashiwa Hospital, Japan; Department of Neurosurgery, Jikei University School of Medicine, Japan
| | - Toshihide Tanaka
- Department of Neurosurgery, Jikei University School of Medicine Kashiwa Hospital, Japan.
| | - Yohei Yamamoto
- Department of Neurosurgery, Jikei University School of Medicine Kashiwa Hospital, Japan
| | - Keisuke Hatano
- Department of Neurosurgery, Jikei University School of Medicine, Japan
| | - Diasuke Ichinose
- Department of Neurosurgery, Jikei University School of Medicine, Japan
| | - Fumiaki Maruyama
- Department of Neurosurgery, Jikei University School of Medicine, Japan
| | - Satoru Tochigi
- Department of Neurosurgery, Jikei University School of Medicine Kashiwa Hospital, Japan
| | - Yuzuru Hasegawa
- Department of Neurosurgery, Jikei University School of Medicine Kashiwa Hospital, Japan
| | - Yuichi Murayama
- Department of Neurosurgery, Jikei University School of Medicine, Japan
| |
Collapse
|
20
|
Wang N, Hu J, Oppong-Gyebi A, Zhu X, Li Y, Yang J, Ruan L, Zhuge Q, Ye S. Elevated blood urea nitrogen is associated with recurrence of post-operative chronic subdural hematoma. BMC Neurol 2020; 20:411. [PMID: 33167883 PMCID: PMC7653870 DOI: 10.1186/s12883-020-01985-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 10/29/2020] [Indexed: 11/30/2022] Open
Abstract
Background Chronic subdural hematoma (CSDH) is fundamentally treatable with about a 2–31% recurrence rate. Recently, there has been renewed interest in the association between Blood Urea Nitrogen (BUN) and intracranial lesion. Therefore, this paper attempts to show the relationship between BUN and CSDH recurrence. Methods A total of 653 CSDH cases with Burr-hole Irrigation (BHI) were enrolled from December 2014 to April 2019. The analyzed parameters included age, gender, comorbidities, laboratory investigations, medication use and hematoma location. The cases were divided into recurrence and non-recurrence groups while postoperative BUN concentration was further separated into quartiles (Q1 ≤ 4.0 mmol/L, 4.0 < Q2 ≤ 4.9 mmol/L, 4.9 < Q3 ≤ 6.4 mmol/L, Q4 > 6.4 mmol/L). Restricted cubic spline regressions and logistic regression models were performed to estimate the effect of BUN on CSDH recurrence. Results CSDH recurrence was observed in 96 (14.7%) cases. Significant distinctions were found between recurrence and non-recurrence groups in postoperative BUN quartiles of cases (P = 0.003). After adjusting for the potential confounders, the odds ratio of recurrence was 3.069 (95%CI =1.488–6.330, p = 0.002) for the highest quartile of BUN compared with the lowest quartile. In multiple-adjusted spline regression, a high BUN level visually showed a significantly high OR value of recurrence risk. Conclusions Elevated BUN at post-operation is significantly associated with the recurrence of CSDH, and it is indicated that high levels of serum BUN after evacuation may serve as a risk factor for CSDH recurrence. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-020-01985-w.
Collapse
Affiliation(s)
- Ning Wang
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China.,Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, China
| | - Jiangnan Hu
- Department of Pharmacology and Neuroscience, University of North Texas Health Science Center, Fort Worth, TX, 76107, USA
| | - Anthony Oppong-Gyebi
- Department of Pharmacology and Neuroscience, University of North Texas Health Science Center, Fort Worth, TX, 76107, USA
| | - Xuanhao Zhu
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China.,Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, China
| | - Yihao Li
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China.,Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, China
| | - Jianjing Yang
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China.,Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, China
| | - Linhui Ruan
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China.,Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, China
| | - Qichuan Zhuge
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China.,Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, China
| | - Sheng Ye
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China. .,Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, Zhejiang, China.
| |
Collapse
|
21
|
Shimizu Y, Park C, Tokuda K. Gradation density hematoma is a predictor of chronic subdural hematoma recurrence associated with inflammation of the outer membrane. Clin Neurol Neurosurg 2020; 194:105839. [PMID: 32388245 DOI: 10.1016/j.clineuro.2020.105839] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/03/2020] [Accepted: 04/04/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Chronic subdural hematoma (CSDH) is a common form of intracranial hemorrhage with a high recurrence rate. This study aimed to determine the CSDH recurrence rate associated with preoperative computed tomography (CT) findings and the pathological examination of the dura and the outer membrane. PATIENTS AND METHODS We retrospectively reviewed the medical records of patients with CSDH who underwent surgery in our hospital between May 2010 and November 2019. CSDHs were classified into four groups according to the hematoma density on CT: low-density hematoma (LDH), gradation-density hematoma (GDH), iso-density-hematoma (IDH), and mixed-density hematoma (MDH). The postoperative recurrence rate was calculated for each group, and we examined whether the recurrence rate correlated with the CT findings. We also took samples of the dura to analyze inflammatory cell infiltration and the blood vessels. RESULTS A total of 388 patients were analyzed. The total recurrence rate was 13.7%. CT findings at admission showed LDH in 50, GDH in 136, IDH in 110, and MDH in 92 patients. The recurrence rate of GDH (23.5%, 32/136) was comparable to the rate of the other CSDH types (11.5%, 61/388). Univariate and multivariate analyses found GDH to be an independent risk factor for the recurrence of CSDH. GDH patients displayed much more angiogenesis and inflammatory cell infiltration in the outer membrane and the dura. CONCLUSION GDH is an independent predictor for CSDH recurrence. The presence of inflammation in GDH might be the primary cause of CSDH recurrence.
Collapse
Affiliation(s)
- Yu Shimizu
- Department of Neurosurgery, Japan Organization of Occupational Health and Safety, Toyama Rousai Hospital, Japan.
| | - Cheho Park
- Department of Neurosurgery, Japan Organization of Occupational Health and Safety, Toyama Rousai Hospital, Japan
| | - Kazuhiko Tokuda
- Department of Neurosurgery, Japan Organization of Occupational Health and Safety, Toyama Rousai Hospital, Japan
| |
Collapse
|
22
|
Efficacy and safety of middle meningeal artery embolization in the management of refractory or chronic subdural hematomas: a systematic review and meta-analysis. Acta Neurochir (Wien) 2020; 162:499-507. [PMID: 31900658 DOI: 10.1007/s00701-019-04161-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 11/30/2019] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Refractory or chronic subdural hematomas (cSDH) constitute a challenging entity that neurosurgeons face frequently nowadays. Middle meningeal artery embolization (MMAE) has emerged in the recent years as a promising treatment option. However, solid evidence that can dictate management guidelines is still lacking. METHODS We conducted a systematic review and meta-analysis (MA) in compliance with the PRISMA guidelines to evaluate the efficacy and safety of MMAE compared with conventional treatments for refractory or cSDH. Databases were searched up to March 2019. Using a random-effects model, meta-analyses of proportions and risk difference were conducted recurrence, need for surgical rescue, and complications. RESULTS Eleven studies (177 patients) were included. Majority (116, 69%) were males with a weighted mean age of 71 + -19.5 years. Meta-analysis of proportions showed treatment failure to be 2.8%, need for surgical rescue 2.7%, and embolization-related complications 1.2%. Meta-analysis of risk-difference between embolized and non-embolized patients showed a 26% (p < 0.001, 95% CI 21%-31%, I2 = 0) lower risk of hematoma recurrence in MMAE. Similarly, in the embolized group, the need for surgical rescue was 20% less (p < 0.001, 95% CI = 12%-27%, I2 = 12.4), and complications were 3.6% less (p = 0.008, 95% CI 1%-6%, I2 = 0) compared to conventional groups. CONCLUSIONS Although MMAE appears to be a promising treatment for refractory or cSDH, drawing definitive conclusions remains limited by paucity of data and small sample sizes. Multicenter, randomized, prospective trials are needed to compare embolization to conventional treatments like watchful waiting, medical management, or surgical evacuation. More extensive research on MMAE could begin a new era in the minimally invasive management of cSDH.
Collapse
|
23
|
Link TW, Boddu S, Marcus J, Rapoport BI, Lavi E, Knopman J. Middle Meningeal Artery Embolization as Treatment for Chronic Subdural Hematoma: A Case Series. Oper Neurosurg (Hagerstown) 2019; 14:556-562. [PMID: 28973653 DOI: 10.1093/ons/opx154] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 06/01/2017] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Traditional treatment for symptomatic subdural hematoma (SDH) has been surgical evacuation, but recurrence rates are high and patients often harbor complex medical comorbidities. Growth and recurrence is thought to be due to the highly friable nature of the vascularized membrane that forms after initial injury. There have been reported cases of middle meningeal artery (MMA) embolization for treatment of recurrent SDH after surgical evacuation with the goal of eliminating the arterial supply to this vascularized membrane. OBJECTIVE To present the first known case series of MMA embolization as upfront treatment for symptomatic chronic SDHs that have failed conservative management in lieu of surgical evacuation. METHODS Five patients with symptomatic chronic SDHs underwent MMA embolization using PVA microparticles at our institution. Size of SDH was recorded in maximum diameter and total volume. RESULTS Four patients underwent unilateral and 1 underwent bilateral MMA embolization successfully. All cases had significant reduction in total volume of SDH at longest follow-up scan: 81.4 to 13.8 cc (7 wk), 48.5 to 8.7 cc (3 wk), 31.7 and 88 to 0 and 17 cc (14 wk, bilateral), 79.3 to 24.2 cc (8 wk), and 53.5 to 0 cc (6 wk). All patients had symptomatic relief with no complications. Histologic analysis of the chronic SDH membrane in a separate patient that required surgery revealed rich neovascularization with many capillaries and few small arterioles. CONCLUSION MMA embolization could present a minimally invasive and low-risk initial treatment alternative to surgery for symptomatic chronic SDH when clinically appropriate.
Collapse
Affiliation(s)
- Thomas W Link
- Department of Neurosurgery, Weill Cornell Medical College, New York Pres-byterian Hospital, New York, New York
| | - Srikanth Boddu
- Department of Neurosurgery, Weill Cornell Medical College, New York Pres-byterian Hospital, New York, New York
| | - Joshua Marcus
- Department of Neurosurgery, Weill Cornell Medical College, New York Pres-byterian Hospital, New York, New York
| | - Benjamin I Rapoport
- Department of Neurosurgery, Weill Cornell Medical College, New York Pres-byterian Hospital, New York, New York
| | - Ehud Lavi
- Department of Pathology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York
| | - Jared Knopman
- Department of Neurosurgery, Weill Cornell Medical College, New York Pres-byterian Hospital, New York, New York
| |
Collapse
|
24
|
Entezami P, Boulos A, Paul A, Nourollahzadeh E, Dalfino J. Contrast enhancement of chronic subdural hematomas after embolization of the middle meningeal artery. Interv Neuroradiol 2019; 25:596-600. [PMID: 31018739 DOI: 10.1177/1591019919843354] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Chronic subdural hematomas are a common neurosurgical presentation. They are difficult to treat, and current interventions - namely surgical evacuation - are not without complications or recurrences. Embolization of the middle meningeal artery is a promising new treatment option for this pathology. We have noted an interesting phenomenon in our patients following endovascular embolization, which is that the subdural hematoma is stained with contrast following the procedure. This ties into the basic physiology of chronic subdurals, which parasitize the middle meningeal artery during the process of membrane formation and neovascularization, which has previously been reported.
Collapse
Affiliation(s)
- Pouya Entezami
- Department of Neurosurgery, Albany Medical Center, Albany, USA
| | - Alan Boulos
- Department of Neurosurgery, Albany Medical Center, Albany, USA
| | - Alexandra Paul
- Department of Neurosurgery, Albany Medical Center, Albany, USA
| | | | - John Dalfino
- Department of Neurosurgery, Albany Medical Center, Albany, USA
| |
Collapse
|
25
|
Link TW, Boddu S, Paine SM, Kamel H, Knopman J. Middle Meningeal Artery Embolization for Chronic Subdural Hematoma: A Series of 60 Cases. Neurosurgery 2018; 85:801-807. [DOI: 10.1093/neuros/nyy521] [Citation(s) in RCA: 102] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 10/02/2018] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
Chronic subdural hematoma (SDH) is a particularly challenging pathology due to high recurrence rates (2%-37%) and complex medical comorbidities that tend to afflict the patient population. Recently, there have been several case series published describing the use of middle meningeal artery (MMA) embolization as an alternative to surgery for treatment of new or recurrent chronic SDH.
OBJECTIVE
To describe our first 60 cases of MMA embolization for chronic SDH.
METHODS
MMA embolization was performed using angiography, selective microcatheterization of the MMA, and infusion of polyvinyl alcohol particles. Outcomes were assessed clinically and with interval imaging studies at 1 d, 2 wk, and 6 wk postprocedure, and additional intervals as indicated.
RESULTS
MMA embolization was performed successfully on 60 total SDHs in 49 patients. This includes upfront treatment for new (not previously treated) SDH in 42, for recurrence in 8, and prophylaxis (soon after surgical evacuation) in 10. There were 3 mortalities (unrelated to the procedure), and no procedural complications. Of the 50 nonprophylactic cases, there were 4 (8.9%) cases of recurrence requiring surgical evacuation, and 31 (68.9%) that had resolution or reduction in size >50% of SDH at longest follow-up. Overall, 41 (91.1%) were stable or decreased in size and able to avoid surgery.
CONCLUSION
MMA embolization may represent a minimally-invasive alternative to surgery for new or recurrent chronic SDH, or as prophylaxis to reduce the risk of recurrence after surgery. Given our encouraging results with a 91% long-term success rate, a large scale clinical trial is warranted.
Collapse
Affiliation(s)
- Thomas W Link
- Department of Neurosurgery, Weill Cornell Medical Institution New York Presbyterian Hospital, New York, New York
| | - Srikanth Boddu
- Department of Neurosurgery, Weill Cornell Medical Institution New York Presbyterian Hospital, New York, New York
| | - Stephanie M Paine
- Department of Neurosurgery, Weill Cornell Medical Institution New York Presbyterian Hospital, New York, New York
| | - Hooman Kamel
- Department of Neurology, Weill Cornell Medical Institution New York Presbyterian Hospital, New York, New York
| | - Jared Knopman
- Department of Neurosurgery, Weill Cornell Medical Institution New York Presbyterian Hospital, New York, New York
| |
Collapse
|
26
|
Fu S, Li F, Bie L. Drug therapy for chronic subdural hematoma: Bench to bedside. J Clin Neurosci 2018; 56:16-20. [DOI: 10.1016/j.jocn.2017.07.034] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 06/21/2017] [Accepted: 07/20/2017] [Indexed: 01/03/2023]
|
27
|
Link TW, Rapoport BI, Paine SM, Kamel H, Knopman J. Middle meningeal artery embolization for chronic subdural hematoma: Endovascular technique and radiographic findings. Interv Neuroradiol 2018; 24:455-462. [PMID: 29720020 DOI: 10.1177/1591019918769336] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background and purpose Embolization of the middle meningeal artery (MMA) has recently been proposed as an alternative to surgery for treatment of chronic subdural hematoma (SDH), and several case reports have been published supporting its efficacy. It has been suggested that the primary pathologic process in chronic SDH is repeated microhemorrhaging into the subdural collection from fragile neovasculature within the SDH membrane that arises from distal branches of the MMA. Embolization could thus provide a means of eliminating this chronic rebleeding. Materials and methods Images were selected from MMA embolization procedures performed at our institution in order to illustrate the technique and theory behind its efficacy for treatment of chronic SDH. Results Images from MMA angiograms demonstrate the variability of MMA anatomy and help illustrate the importance of avoiding potential ophthalmic collaterals and branches supplying cranial nerves. The findings of irregular wispiness of the distal MMA vasculature, contrast outlining of the SDH membrane on angiography, and homogenous increased density within the SDH on postembolization head computed tomography are described. Conclusion MMA embolization may provide a safe alternative for treatment of chronic SDH, but careful angiographic assessment of MMA anatomy should be performed to avoid potential complications. The findings illustrated here lend support to the theory that the pathologic process of chronic SDH is repeated leakage of blood products from an inflamed, abnormal arterial neovasculature within the SDH membrane that arises from the MMA, and thus selective embolization could provide an effective treatment.
Collapse
Affiliation(s)
- Thomas W Link
- 1 Department of Neurosurgery, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Benjamin I Rapoport
- 1 Department of Neurosurgery, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Stephanie M Paine
- 1 Department of Neurosurgery, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Hooman Kamel
- 2 Department of Neurology, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Jared Knopman
- 1 Department of Neurosurgery, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, NY, USA
| |
Collapse
|
28
|
Subdural Abnormal Communicating Vessel in Chronic Subdural Hematoma. J Craniofac Surg 2018; 29:e261-e262. [PMID: 29381635 DOI: 10.1097/scs.0000000000004286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Traditionally, lacerations of bridging vessels were surmised to cause chronic subdural hematoma (CSDH), although neither observation studies nor medical research was able to testify this. Nowadays, an inflammatory process is known to take place in the development of CSDH. Of note, post-traumatic angiogenesis at its early stage also features inflammation with immune cell infiltration. The authors found a patient suffering from CSDH with unusual angiogenesis between dura and pia matters. The observation of dura-and-pia angiogenesis may be a piece of evidence to underline compensatory reaction of central nervous system to offset the negative effects produced by CSDH, and points out to a possible approach of bolstering angiogenesis to manage ischemic diseases in cerebral hemispheres.
Collapse
|
29
|
Abstract
Objective: The proportion of the super-aged population (at the age of 80 or above) in patients with chronic subdural hematoma (CSDH) and the incidence of CSDH of the population have been increasing. Since it is widely accepted that YL-1 needle is effective in CSDH treatment, this paper aimed to probe into the efficacy of YL-1 needle in minimally invasive surgery for super-aged (at the age of 80–90) CSDH patients. Methods: A retrospective analysis on the clinical information of 17 super-aged CSDH patients having received the YL-1 needle puncture treatment provided by the hospital from May 2012 to December 2016 was performed. At the same time, another 19 CSDH patients (ages 60–79) who were hospitalized during the same period were randomly selected to form a control group. The same surgical treatment was provided for both groups to observe and compare the treatment efficacy. Results: The patients of both groups were cured and discharged. Among the super-aged patients, there was 1 patient with postoperative hematoma recurrence, 1 patient with pneumocephalus, and 1 patient with wound infection; among the aged patients, 1 reported postoperative recurrence and 2 had pneumocephalus; The average length of stay of the super-aged group was 9.235 ± 2.948 days while that of the aged group was 7.316 ± 3.660 days, which showed no statistical difference. Conclusion: The YL-1 needle puncture treatment is safe and efficacious for both the super-aged and the aged CSDH patients.
Collapse
|
30
|
Sahyouni R, Goshtasbi K, Mahmoodi A, Tran DK, Chen JW. Chronic Subdural Hematoma: A Perspective on Subdural Membranes and Dementia. World Neurosurg 2017; 108:954-958. [PMID: 28935547 PMCID: PMC5705282 DOI: 10.1016/j.wneu.2017.09.063] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 09/07/2017] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To review the complex pathogenesis of the subdural membrane and the link between head trauma, dementia, and dural lymphatics. METHODS A thorough literature search of published English-language articles was performed using PubMed, Ovid, and Cochrane databases. RESULTS Chronic subdural hematoma (cSDH) is a common intracranial pathology and a leading cause of reversible dementia. cSDH is projected to affect at least 60,000 new individuals in the United States annually by 2030. This condition can result from mild to moderate head trauma that leads to hemorrhaging in the dura-arachnoid interface. The short-term and long-term effects of cSDH and the subdural membrane on the pathogenesis of dementia and the newly discovered dural lymphatics is a topic of increasing importance. CONCLUSIONS Further research into the possible link between traumatic brain injury and cSDH in particular and dural lymphatics and intracranial fluid dynamics is warranted.
Collapse
Affiliation(s)
- Ronald Sahyouni
- University of California, Irvine, School of Medicine, Irvine, California, USA; Department of Biomedical Engineering, University of California, Irvine, Samueli School of Engineering, Irvine, California, USA
| | - Khodayar Goshtasbi
- University of California, Irvine, School of Medicine, Irvine, California, USA
| | - Amin Mahmoodi
- Department of Neurological Surgery, University of California, Irvine, Irvine, California, USA
| | - Diem Kieu Tran
- Department of Neurological Surgery, University of California, Irvine, Irvine, California, USA
| | - Jefferson W Chen
- Department of Neurological Surgery, University of California, Irvine, Irvine, California, USA.
| |
Collapse
|
31
|
Correlation of vascular endothelial growth factor with magnetic resonance imaging in chronic subdural hematomas. J Neurol Sci 2017; 377:149-154. [DOI: 10.1016/j.jns.2017.04.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 03/31/2017] [Accepted: 04/10/2017] [Indexed: 02/02/2023]
|
32
|
Edlmann E, Giorgi-Coll S, Whitfield PC, Carpenter KLH, Hutchinson PJ. Pathophysiology of chronic subdural haematoma: inflammation, angiogenesis and implications for pharmacotherapy. J Neuroinflammation 2017; 14:108. [PMID: 28558815 PMCID: PMC5450087 DOI: 10.1186/s12974-017-0881-y] [Citation(s) in RCA: 289] [Impact Index Per Article: 41.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 05/15/2017] [Indexed: 02/08/2023] Open
Abstract
Chronic subdural haematoma (CSDH) is an encapsulated collection of blood and fluid on the surface of the brain. Historically considered a result of head trauma, recent evidence suggests there are more complex processes involved. Trauma may be absent or very minor and does not explain the progressive, chronic course of the condition. This review focuses on several key processes involved in CSDH development: angiogenesis, fibrinolysis and inflammation. The characteristic membrane surrounding the CSDH has been identified as a source of fluid exudation and haemorrhage. Angiogenic stimuli lead to the creation of fragile blood vessels within membrane walls, whilst fibrinolytic processes prevent clot formation resulting in continued haemorrhage. An abundance of inflammatory cells and markers have been identified within the membranes and subdural fluid and are likely to contribute to propagating an inflammatory response which stimulates ongoing membrane growth and fluid accumulation. Currently, the mainstay of treatment for CSDH is surgical drainage, which has associated risks of recurrence requiring repeat surgery. Understanding of the underlying pathophysiological processes has been applied to developing potential drug treatments. Ongoing research is needed to identify if these therapies are successful in controlling the inflammatory and angiogenic disease processes leading to control and resolution of CSDH.
Collapse
Affiliation(s)
- Ellie Edlmann
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Box 167, Cambridge Biomedical Campus, Cambridge, CB2 0QQ UK
| | - Susan Giorgi-Coll
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Box 167, Cambridge Biomedical Campus, Cambridge, CB2 0QQ UK
| | - Peter C. Whitfield
- Southwest Neurosurgical Centre, Plymouth Hospitals NHS Trust, Plymouth, PL6 8DH UK
| | - Keri L. H. Carpenter
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Box 167, Cambridge Biomedical Campus, Cambridge, CB2 0QQ UK
| | - Peter J. Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Box 167, Cambridge Biomedical Campus, Cambridge, CB2 0QQ UK
| |
Collapse
|
33
|
Sahyouni R, Mahboubi H, Tran P, Roufail JS, Chen JW. Membranectomy in Chronic Subdural Hematoma: Meta-Analysis. World Neurosurg 2017; 104:418-429. [PMID: 28512051 DOI: 10.1016/j.wneu.2017.05.030] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 05/02/2017] [Accepted: 05/04/2017] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Initial management strategies of chronic subdural hematoma (cSDH) are controversial and range from bedside twist-drill or burr-hole drainage to craniotomy with membranectomy (CWM). We aim to 1) perform a meta-analysis of the available data on the outcomes of CWM for treatment of cSDH in published English-language literature and 2) evaluate collective outcomes of CWM with respect to morbidity, mortality, and recurrence rates. METHODS A search of English-language literature performed in PubMed, Ovid, and Cochrane databases using key words ("subdural hematoma" or "chronic subdural hematoma") and ("membrane" or "membranectomy") from inception to December 2016 was conducted. Studies reporting outcomes of CWM in cSDH were included. Mortality, morbidity, follow-up duration, and recurrence rate data were extracted and analyzed. Pooled estimates and confidence intervals (CIs) were calculated for all outcomes using a random-effects model. RESULTS Of 301 articles found, 17 articles containing 5369 patients met our eligibility criteria. Mean follow-up duration ranged from 1-30.8 months. Collective mean mortality and morbidity rates were 3.7% and 6.9%, respectively (95% CI 2-5.4% and 2.1-11.6%; P < 0.001 and P = 0.004). The collective mean recurrence rate was 7.6% (95% CI: 5%-10.2%; P < 0.001). CONCLUSIONS Clinical data on outcomes of CWM in cSDH are limited to single institutional analyses, with considerable variation in recurrence rates and follow-up time. The rates we reported are comparable with the 5% mortality and 3%-12% morbidity rates and lower than the 10%-21% recurrence rate in the literature for burr holes or craniotomy without membranectomy. This meta-analysis provides an in-depth analysis of available data and reviews reported outcomes.
Collapse
Affiliation(s)
- Ronald Sahyouni
- School of Medicine MSTP, University of California, Irvine, California, USA; Department of Biomedical Engineering, University of California, Irvine, California, USA
| | - Hossein Mahboubi
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California, USA
| | - Peter Tran
- Department of Neurological Surgery, University of California, Irvine, California, USA
| | - John S Roufail
- Department of Neurological Surgery, University of California, Irvine, California, USA
| | - Jefferson W Chen
- Department of Neurological Surgery, University of California, Irvine, California, USA.
| |
Collapse
|
34
|
Yan K, Gao H, Zhou X, Wu W, Xu W, Xu Y, Gong K, Xue X, Wang Q, Na H. A retrospective analysis of postoperative recurrence of septated chronic subdural haematoma: endoscopic surgery versus burr hole craniotomy. Neurol Res 2017; 39:803-812. [PMID: 28502216 DOI: 10.1080/01616412.2017.1321709] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Kaixuan Yan
- Department of Neurosurgery, The Affiliated Jiangyin Hospital, School of Medicine, Southeast University, Jiangyin, China
| | - Heng Gao
- Department of Neurosurgery, The Affiliated Jiangyin Hospital, School of Medicine, Southeast University, Jiangyin, China
| | - Xinmin Zhou
- Department of Neurosurgery, The Affiliated Jiangyin Hospital, School of Medicine, Southeast University, Jiangyin, China
| | - Wei Wu
- Department of Neurosurgery, The Affiliated Jiangyin Hospital, School of Medicine, Southeast University, Jiangyin, China
| | - Weidong Xu
- Department of Neurosurgery, The Affiliated Jiangyin Hospital, School of Medicine, Southeast University, Jiangyin, China
| | - Yu Xu
- Department of Neurosurgery, The Affiliated Jiangyin Hospital, School of Medicine, Southeast University, Jiangyin, China
| | - Kai Gong
- Department of Neurosurgery, The Affiliated Jiangyin Hospital, School of Medicine, Southeast University, Jiangyin, China
| | - Xinchen Xue
- Department of Neurosurgery, The Affiliated Jiangyin Hospital, School of Medicine, Southeast University, Jiangyin, China
| | - Qipin Wang
- Department of Neurosurgery, The Affiliated Jiangyin Hospital, School of Medicine, Southeast University, Jiangyin, China
| | - Hanrong Na
- Department of Neurosurgery, The Affiliated Jiangyin Hospital, School of Medicine, Southeast University, Jiangyin, China
| |
Collapse
|
35
|
Schaumann A, Klene W, Rosenstengel C, Ringel F, Tüttenberg J, Vajkoczy P. COXIBRAIN: results of the prospective, randomised, phase II/III study for the selective COX-2 inhibition in chronic subdural haematoma patients. Acta Neurochir (Wien) 2016; 158:2039-2044. [PMID: 27605230 DOI: 10.1007/s00701-016-2949-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 08/25/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Chronic subdural haematomas (cSDHs) have shown an increasing incidence in an ageing population over the last 20 years, while unacceptable recurrence rates of up to 30 % persist. The recurrence rate of cSDH seems to be related to the excessive neoangiogenesis in the parietal membrane, which is mediated via vascular endothelial growth factor (VEGF). This is found to be elevated in the haematoma fluid and is dependent on eicosanoid/prostaglandin and thromboxane synthesis via cyclo-oxygenase-2 (COX-2). With this investigator-initiated trial (IIT) it was thought to diminish the recurrence rate of operated-on cSDHs by administering a selective COX-2 inhibitor (Celecoxib) over 4 weeks' time postoperatively in comparison to a control group. METHOD The thesis of risk reduction of cSDH recurrence in COX-2-inhibited patients was to be determined in a prospective, randomised, two-armed, open phase-II/III study with inclusion of 180 patients over a 2-year time period in four German university hospitals. The treated- and untreated-patient data were to be analysed by Fisher's exact test (significance level of alpha, 0.05 [two-sided]). RESULTS After screening of 246 patients from January 2009 to April 2010, the study had to be terminated prematurely as only 23 patients (9.3 %) could be enrolled because of on-going non-steroid anti-rheumatic (NSAR) drug treatment or contraindication to Celecoxib medication. In the study population, 13 patients were treated in the control group (six women, seven men; average age 66.8 years; one adverse event (AE)/serious adverse event (SAE) needing one re-operation because of progressive cSDH (7.7 %); ten patients were treated in the treatment group (one woman, nine men; average age 64.7 years; five AEs/SAEs needing two re-operations because of one progressive cSDH and one wound infection [20 %]). Significance levels are obsolete because of insufficient patient numbers. CONCLUSIONS The theoretical advantage of COX-2 inhibition in the recurrent cSDH could not be transferred into the treatment of German cSDH patients as 66.6 % of the patients showed strict contraindications for Celecoxib. Furthermore, 55 % of the patients were already treated with some kind of COX-2 inhibition and, nevertheless, developed cSDH. Thus, although conceptually appealing, an anti-angiogenic therapy with COX-2 inhibitors for cSDH could not be realised in this patient population due to the high prevalence of comorbidities excluding the administration of COX2 inhibitors.
Collapse
|
36
|
Yan K, Gao H, Wang Q, Xu X, Wu W, Zhou X, Xu W, Ye F. Endoscopic surgery to chronic subdural hematoma with neovessel septation: technical notes and literature review. Neurol Res 2016; 38:467-76. [DOI: 10.1080/01616412.2016.1139772] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
37
|
A case of complete clearance of chronic subdural hematoma accompanied by recurrent glioblastoma multiforme after administration of bevacizumab. Neurosurg Rev 2016; 39:525-9. [PMID: 26919835 DOI: 10.1007/s10143-016-0704-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2014] [Revised: 05/23/2015] [Accepted: 01/27/2016] [Indexed: 10/22/2022]
Abstract
The efficacy of bevacizumab, a humanized monoclonal antibody against vascular endothelial growth factor (VEGF), as an adjuvant therapy against various malignant tumors was recently established. Its pharmacological effects in malignant tumors, including gliomas, were speculated to involve neovascularization inhibition and vascular permeability. Recently, it has been reported that the outer membrane of chronic subdural hematoma (CSDH) contains high levels of VEGF, which were implicated in neovascularization of the outer membrane. Furthermore, studies suggested that VEGF has the etiology in CSDH development, although its involvement is not fully understood. Here, we report the first case of chronic subdural hematoma that was improved by bevacizumab administration for recurrent glioblastoma. The present case could contribute to the hypothesis that VEGF may be associated with CSDH. We also discuss the pathogenesis and mechanism of CSDH recurrence from the viewpoint of VEGF function.
Collapse
|
38
|
Park MH, Kim CH, Cho TG, Park JK, Moon JG, Lee HK. Clinical Features According to the Histological Types of the Outer Membrane of Chronic Subdural Hematoma. Korean J Neurotrauma 2015; 11:70-4. [PMID: 27169068 PMCID: PMC4847501 DOI: 10.13004/kjnt.2015.11.2.70] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 06/17/2015] [Accepted: 08/22/2015] [Indexed: 11/15/2022] Open
Abstract
Objective The aim of our study was to classify the outer membrane of chronic subdural hematoma (CSDH) histologically and to determine the clinical and radiological meaning of the classified membranes. Methods The outer membrane specimen of 31 patients who underwent surgery for CSDH were acquired in this study. The specimen was classified into four types and each were analyzed of the symptoms on the admission day and during the period from trauma to surgery. The radiological features such as subdural fluid density, Hounsfield number, thickness of the hematoma, and midline shift were analyzed. Results There were 6% of type I, 29% of type II, 39% of type III, and 26% of type IV neomembranes. The cases of CSDH accompanied by neurologic deficit were highest from type IV of 63%, followed by type II with 56%. On the radiological findings such as Hounsfield unit, hematoma thickness and midline shift, only hematoma thickness between type II and III were statistically significant (p=0.021). The hematoma thickness and midline shift were greatest in type II. On computed tomography scans, the isodense, hyperdense and laminar type that shows the high recurrence rate formed 75% of type II and 67% of type IV while type III had the low possibility of recurrence rate (33%). Conclusion We have identified that the outer membrane have the tendency to develop from type I to IV in time while type II and type IV may have more risk of neurologic deficit and the high possibility of recurrence.
Collapse
Affiliation(s)
- Min Ho Park
- Department of Neurosurgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Chang Hyun Kim
- Department of Neurosurgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Tack Geun Cho
- Department of Neurosurgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | | | - Jae Gon Moon
- Department of Neurosurgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Ho Kook Lee
- Department of Neurosurgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| |
Collapse
|
39
|
An improved electronic twist-drill craniostomy procedure with post-operative urokinase instillation in treating chronic subdural hematoma. Clin Neurol Neurosurg 2015; 136:61-5. [DOI: 10.1016/j.clineuro.2015.05.037] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Revised: 05/27/2015] [Accepted: 05/31/2015] [Indexed: 11/18/2022]
|
40
|
Hua C, Zhao G, Feng Y, Yuan H, Song H, Bie L. Role of Matrix Metalloproteinase-2, Matrix Metalloproteinase-9, and Vascular Endothelial Growth Factor in the Development of Chronic Subdural Hematoma. J Neurotrauma 2015; 33:65-70. [PMID: 25646653 DOI: 10.1089/neu.2014.3724] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Chronic subdural hematoma (CSDH) is an inflammatory and angiogenic disease. Vascular endothelial growth factor (VEGF) has an important effect on the pathological progression of CSDH. The matrix metalloproteinases (MMPs) and VEGF also play a significant role in pathological angiogenesis. Our research was to investigate the level of MMPs and VEGF in serum and hematoma fluid. Magnetic Resonance Imaging (MRI) shows the characteristics of different stages of CSDH. We also analyzed the relationship between the level of VEGF in subdural hematoma fluid and the appearances of the patients' MRI. We performed a study comparing serum and hematoma fluid in 37 consecutive patients with primary CSDHs using enzyme-linked immunosorbent assay (ELISA). MMP-2 and MMP-9 activity was assayed by the gelatin zymography method. The patients were divided into five groups according to the appearance of the hematomas on MRI: group 1 (T1-weighted low, T2-weighted low, n=4), group 2 (T1-weighted high, T2-weighted low, n=11), group 3 (T1-weighted mixed, T2-weighted mixed, n=9), group 4 (T1-weighted high, T2-weighted high, n=5), and group 5 (T1-weighted low, T2-weighted high, n=8). Neurological status was assessed by Markwalder score on admission and at follow-up. The mean age, sex, and Markwalder score were not significantly different among groups. The mean concentration of VEGF, MMP-2, and MMP-9 were significantly higher in hematoma fluid than in serum (p<0.01). The level of pro-MMP-2 was higher in hematoma fluid (p<0.01). Measurement of MMP-9 showed both pro and active forms in both groups, but levels were higher in hematoma fluid (p<0.01 and p<0.01, respectively). Mean VEGF concentration was highest in group 1 (21,979.3±1387.3 pg/mL), followed by group 2 (20,060.1±1677.2 pg/mL), group 3 (13,746.5±3529.7 pg/mL), group 4 (7523.2±764.9 pg/mL), and lowest in group 5 (6801.9±618.7 pg/mL). There was a significant correlation between VEGF concentrations and MRI type (r=0.854). The present investigation is the first report showing that the concentrations of MMP-2 and MMP-9 are significantly elevated in hematoma fluid, suggesting that the MMPs/VEGF system may be involved in the angiogenesis of CSDH. We also demonstrate a significant correlation between the concentrations of VEGF and MRI appearance. This finding supports the hypothesis that high VEGF concentration in the hematoma fluid is of major pathophysiological importance in the generation and steady increase of the hematoma volume, as well as the determination of MRI appearance.
Collapse
Affiliation(s)
- Cong Hua
- 1 Department of Neurosurgery, Norman Bethune College of Medicine, Jilin University , Changchun, China
| | - Gang Zhao
- 1 Department of Neurosurgery, Norman Bethune College of Medicine, Jilin University , Changchun, China
| | - Yan Feng
- 2 Department of Radiology of the First Hospital, Norman Bethune College of Medicine, Jilin University , Changchun, China
| | - Hongyan Yuan
- 3 Department of Immunology, Norman Bethune College of Medicine, Jilin University , Changchun, China
| | - Hongmei Song
- 1 Department of Neurosurgery, Norman Bethune College of Medicine, Jilin University , Changchun, China
| | - Li Bie
- 1 Department of Neurosurgery, Norman Bethune College of Medicine, Jilin University , Changchun, China .,4 Department of Pathology and Laboratory Medicine, University of California , Irvine, California
| |
Collapse
|
41
|
Park KS, Park SH, Hwang SK, Kim C, Hwang JH. Correlation of the Beta-trace protein and inflammatory cytokines with magnetic resonance imaging in chronic subdural hematomas : a prospective study. J Korean Neurosurg Soc 2015; 57:235-41. [PMID: 25932289 PMCID: PMC4414766 DOI: 10.3340/jkns.2015.57.4.235] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 01/06/2015] [Accepted: 02/13/2015] [Indexed: 11/27/2022] Open
Abstract
Objective Magnetic resonance imaging (MRI) of chronic subdural hematoma (CSDH) detects various patterns, which can be attributed to many factors. The purpose of this study was to measure the level of interleukin-6 (IL-6), interleukin-8 (IL-8), and highly specific protein [beta-trace protein (βTP)] for cerebrospinal fluid (CSF) in CSDHs, and correlate the levels of these markers with the MRI findings. Methods Thirty one patients, treated surgically for CSDH, were divided on the basis of MRI findings into hyperintense and non-hyperintense groups. The concentrations of IL-6, IL-8, and βTP in the subdural fluid and serum were measured. The βTP was considered to indicate an admixture of CSF to the subdural fluid if βTP in the subdural fluid (βTPSF)/βTP in the serum (βTPSER)>2. Results The mean concentrations of IL-6 and IL-8 of the hyperintense group (n=17) of T1-WI MRI were 3975.1±1040.8 pg/mL and 6873.2±6365.4 pg/mL, whereas them of the non-hyperintense group (n=14) were 2173.5±1042.1 pg/mL and 2851.2±6267.5 pg/mL (p<0.001 and p=0.004). The mean concentrations of βTPSF and the ratio of βTPSF/βTPSER of the hyperintense group (n=13) of T2-WI MRI were 7.3±2.9 mg/L and 12.6±5.4, whereas them of the non-hyperintense group (n=18) were 4.3±2.3 mg/L and 7.5±3.9 (p=0.011 and p=0.011). Conclusion The hyperintense group on T1-WI MRI of CSDHs exhibited higher concentrations of IL-6 and IL-8 than non-hyperintense group. And, the hyperintese group on T2-WI MRI exhibited higher concentrations of βTPSF and the ratio of βTPSF/βTPSER than non-hyperintense group. These findings appear to be associated with rebleeding and CSF admixture in the CSDHs.
Collapse
Affiliation(s)
- Ki-Su Park
- Department of Neurosurgery, Kyungpook National University School of Medicine, Daegu, Korea
| | - Seong-Hyun Park
- Department of Neurosurgery, Kyungpook National University School of Medicine, Daegu, Korea
| | - Sung-Kyoo Hwang
- Department of Neurosurgery, Kyungpook National University School of Medicine, Daegu, Korea
| | - Chaekyung Kim
- Department of Neurosurgery, Kyungpook National University School of Medicine, Daegu, Korea
| | - Jeong-Hyun Hwang
- Department of Neurosurgery, Kyungpook National University School of Medicine, Daegu, Korea
| |
Collapse
|
42
|
Ikeda O, Minami N, Yamazaki M, Koda M, Morinaga T. Hemorrhagic lumbar facet cysts accompanying a spinal subdural hematoma at the same level. J Spinal Cord Med 2015; 38:239-44. [PMID: 24976137 PMCID: PMC4397208 DOI: 10.1179/2045772314y.0000000216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
CONTEXT We present a rare and interesting case of hemorrhagic lumbar facet cysts accompanying a spinal subdural hematoma at the same level suggesting a possible mechanism by which spinal subdural hematomas can arise. FINDINGS A 71-year-old man presented with persistent sciatic pain and intermittent claudication. Magnetic resonance imaging demonstrated a multilocular mass lesion that showed high signal intensity in both T1- and T2-weighted images, and was located both inside and outside of the spinal canal. Computed tomographic myelography showed a cap-shaped block of the dural tube at L5 and computed tomography with L5-S facet arthrography demonstrated cystic masses. The patient was diagnosed with lumbar radiculopathy caused by hemorrhagic facet cysts, and then progressed to surgical treatment. Surgery revealed that the cysts contained blood clots, and intraoperative findings that the inside of the dural tube appeared blackish and that the dural tube was tensely ballooned after removal of the cysts led us to explorative durotomy. The durotomy demonstrated concentrated old blood pooling both in the dorsal and ventral subdural space, and these spaces were subsequently drained. After surgery, his sciatic pain and intermittent claudication resolved. There was no evidence of cyst mass recurrence at 2 years of follow-up. CONCLUSION We propose a newly described mechanism for the formation of spinal subdural hematomas. We recommend surgeons be alert to epidural lesions causing repeated acute compression of the dural tube, which can cause spinal subdural hematoma, and consider the possible coexistence of these lesions in diagnosis and strategic surgical decisions.
Collapse
Affiliation(s)
- Osamu Ikeda
- Department of Orthopedic Surgery, Kashiwa City Kashiwa Hospital, Kashiwa, Chiba, Japan,Correspondence to: Osamu Ikeda, Department of Orthopedic Surgery, Kashiwa City Kashiwa Hospital, 1-3 Fuse, Kashiwa, Chiba 277-0825, Japan.
| | - Norihiko Minami
- Department of Orthopedic Surgery, Kashiwa City Kashiwa Hospital, Kashiwa, Chiba, Japan
| | - Masashi Yamazaki
- Department of Orthopedic Surgery, Tsukuba University, Tsukuba, Ibaraki, Japan
| | - Masao Koda
- Department of Orthopedic Surgery, Chiba University Graduate School of Medicine, Chuo-ku, Chiba, Japan
| | - Tatsuo Morinaga
- Department of Orthopedic Surgery, Kashiwa City Kashiwa Hospital, Kashiwa, Chiba, Japan
| |
Collapse
|
43
|
Kameda K, Shono T, Takagishi S, Kono S, Aoki T, Ito Y, Kamimura T, Sugita Y, Ohshima K. Epstein-Barr virus-positive diffuse large B-cell primary central nervous system lymphoma associated with organized chronic subdural hematoma: A case report and review of the literature. Pathol Int 2015; 65:138-43. [DOI: 10.1111/pin.12242] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 11/20/2014] [Indexed: 11/30/2022]
Affiliation(s)
| | - Tadahisa Shono
- Department of Neurosurgery; Harasanshin Hospital; Fukuoka Japan
| | - Soh Takagishi
- Department of Neurosurgery; Harasanshin Hospital; Fukuoka Japan
| | - Shinji Kono
- Department of Pathology; Harasanshin Hospital; Fukuoka Japan
| | - Takatoshi Aoki
- Department of Hematology; Harasanshin Hospital; Fukuoka Japan
| | - Yoshikiyo Ito
- Department of Hematology; Harasanshin Hospital; Fukuoka Japan
| | | | - Yasuo Sugita
- Department of Pathology; Kurume University School of Medicine; Kurume Japan
| | - Koichi Ohshima
- Department of Pathology; Kurume University School of Medicine; Kurume Japan
| |
Collapse
|
44
|
Liu W, Bakker NA, Groen RJM. Chronic subdural hematoma: a systematic review and meta-analysis of surgical procedures. J Neurosurg 2014; 121:665-73. [DOI: 10.3171/2014.5.jns132715] [Citation(s) in RCA: 152] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
In this paper the authors systematically evaluate the results of different surgical procedures for chronic subdural hematoma (CSDH).
Methods
The MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and other databases were scrutinized according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) statement, after which only randomized controlled trials (RCTs) and quasi-RCTs were included. At least 2 different neurosurgical procedures in the management of chronic subdural hematoma (CSDH) had to be evaluated. Included studies were assessed for the risk of bias. Recurrence rates, complications, and outcome including mortality were taken as outcome measures. Statistical heterogeneity in each meta-analysis was assessed using the T2 (tau-squared), I2, and chi-square tests. The DerSimonian-Laird method was used to calculate the summary estimates using the fixed-effect model in meta-analysis.
Results
Of the 297 studies identified, 19 RCTs were included. Of them, 7 studies evaluated the use of postoperative drainage, of which the meta-analysis showed a pooled OR of 0.36 (95% CI 0.21–0.60; p < 0.001) in favor of drainage. Four studies compared twist drill and bur hole procedures. No significant differences between the 2 methods were present, but heterogeneity was considered to be significant. Three studies directly compared the use of irrigation before drainage. A fixed-effects meta-analysis showed a pooled OR of 0.49 (95% CI 0.21–1.14; p = 0.10) in favor of irrigation. Two studies evaluated postoperative posture. The available data did not reveal a significant advantage in favor of the postoperative supine posture. Regarding positioning of the catheter used for drainage, it was shown that a frontal catheter led to a better outcome. One study compared duration of drainage, showing that 48 hours of drainage was as effective as 96 hours of drainage.
Conclusions
Postoperative drainage has the advantage of reducing recurrence without increasing complications. The use of a bur hole or twist drill does not seem to make any significant difference in recurrence rates or other outcome measures. It seems that irrigation may lead to a better outcome. These results may lead to more standardized procedures.
Collapse
Affiliation(s)
- Weiming Liu
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, China; and
| | - Nicolaas A. Bakker
- 2Department of Neurosurgery, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Rob J. M. Groen
- 2Department of Neurosurgery, University Medical Center Groningen, University of Groningen, The Netherlands
| |
Collapse
|
45
|
Effects of atorvastatin on the inflammation regulation and elimination of subdural hematoma in rats. J Neurol Sci 2014; 341:88-96. [DOI: 10.1016/j.jns.2014.04.009] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Revised: 04/01/2014] [Accepted: 04/03/2014] [Indexed: 11/18/2022]
|
46
|
Effects of atorvastatin on chronic subdural hematoma: A preliminary report from three medical centers. J Neurol Sci 2014; 336:237-42. [DOI: 10.1016/j.jns.2013.11.005] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Revised: 09/29/2013] [Accepted: 11/04/2013] [Indexed: 12/14/2022]
|
47
|
Saito A, Narisawa A, Takasawa H, Morita T, Sannohe S, Sasaki T, Kurotaki H, Nishijima M. Expression of the TGF-β-ALK-1 pathway in dura and the outer membrane of chronic subdural hematomas. Neurol Med Chir (Tokyo) 2013; 54:357-62. [PMID: 24305026 PMCID: PMC4533438 DOI: 10.2176/nmc.oa2013-0019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Neovascularization of the outer membrane plays a critical role in the development and enlargement of chronic subdural hematomas (CSHs) and vascular endothelial growth factor (VEGF) may promote their progression. However, the precise mechanisms remain to be determined. We focused on the signaling pathway upstream of VEGF, transforming growth factor β (TGF-β), and activin receptor-like kinase 1 (ALK-1) to identify the mechanisms underlying the neovascularization of the outer membrane of CSH. Retrospective comparative study was conducted on 15 consecutive patients diagnosed as CSH with burr-hole drainage. Dura and the outer membrane were collected. We immunohistochemically examined the expression of VEGF, integrin-α, TGF-β, and ALK-1 on the outer membrane and dura of CSH and compared our findings with control samples and the signal intensity of hematomas on computed tomography (CT) scans. VEGF and integrin-α expression was markedly up-regulated in both the dura and outer membrane of CSH, the expression of TGF-β and ALK-1 in the dura was slightly increased in the dura and markedly up-regulated in the outer membrane. There was no significant correlation between their expression and CT density. Here we first report the expression of TGF-β and ALK-1 in the outer membrane and dura mater of CSH. We suggest that the TGF-β–ALK-1 pathway and VEGF affect neovascularization and the progression of CSH.
Collapse
Affiliation(s)
- Atsushi Saito
- Department of Neurosurgery, Aomori Prefectural Central Hospital
| | | | | | | | | | | | | | | |
Collapse
|
48
|
Kalamatianos T, Stavrinou LC, Koutsarnakis C, Psachoulia C, Sakas DE, Stranjalis G. PlGF and sVEGFR-1 in chronic subdural hematoma: implications for hematoma development. J Neurosurg 2013; 118:353-7. [DOI: 10.3171/2012.10.jns12327] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Object
A considerable body of evidence indicates that inflammation and angiogenesis play a significant role in the development and progression of chronic subdural hematoma (CSDH). While various experimental and clinical studies have implicated placental growth factor (PlGF) in the processes that underpin pathological angiogenesis, no study has thus far investigated its expression in CSDH. The actions of PlGF and its related proangiogenic vascular endothelial growth factor (VEGF) are antagonized by a high-affinity soluble receptor, namely soluble VEGF receptor–1 (sVEGFR-1), and thus the ratio between sVEGFR-1 and angiogenic factors provides an index of angiogenic capacity.
Methods
In the present study, using an automated electrochemiluminescence assay, levels of PlGF and sVEGFR-1 were quantified in serum and hematoma fluid obtained in 16 patients with CSDH.
Results
Levels of PlGF and sVEGFR-1 were significantly higher in hematoma fluid than in serum (p < 0.0001). In serum, levels of sVEGFR-1 were higher than those of PlGF (p < 0.0001), whereas in hematoma fluid this difference was not apparent. Furthermore, the ratio of sVEGFR-1 to PlGF was significantly lower in hematoma fluid than in serum (p < 0.0001).
Conclusions
Given previous evidence indicating a role for PlGF in promoting angiogenesis, inflammatory cell chemotaxis, and stimulation, as well as its ability to amplify VEGF-driven signaling under conditions favoring pathological angiogenesis, enhanced expression of PlGF in hematoma fluid suggests the involvement of this factor in the mechanisms of inflammation and angiogenesis in CSDH. Furthermore, a reduced ratio of sVEGFR-1 to PlGF in hematoma fluid is consistent with the proangiogenic capacity of CSDH. Future studies are warranted to clarify the precise role of PlGF and sVEGFR-1 in CSDH.
Collapse
Affiliation(s)
- Theodosis Kalamatianos
- 1Hellenic Centre of Neurosurgical Research “Professor Petros S. Kokkalis”
- 2Department of Neurosurgery, University of Athens; and
| | - Lampis C. Stavrinou
- 1Hellenic Centre of Neurosurgical Research “Professor Petros S. Kokkalis”
- 2Department of Neurosurgery, University of Athens; and
| | - Christos Koutsarnakis
- 1Hellenic Centre of Neurosurgical Research “Professor Petros S. Kokkalis”
- 2Department of Neurosurgery, University of Athens; and
| | | | - Damianos E. Sakas
- 1Hellenic Centre of Neurosurgical Research “Professor Petros S. Kokkalis”
- 2Department of Neurosurgery, University of Athens; and
| | - George Stranjalis
- 1Hellenic Centre of Neurosurgical Research “Professor Petros S. Kokkalis”
- 2Department of Neurosurgery, University of Athens; and
| |
Collapse
|
49
|
Berghauser Pont LM, Dammers R, Schouten JW, Lingsma HF, Dirven CM. In Reply. Neurosurgery 2012. [DOI: 10.1227/neu.0b013e31824bcd84] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
|
50
|
Stanisic M, Aasen AO, Pripp AH, Lindegaard KF, Ramm-Pettersen J, Lyngstadaas SP, Ivanovic J, Konglund A, Ilstad E, Sandell T, Ellingsen O, Sæhle T. Local and systemic pro-inflammatory and anti-inflammatory cytokine patterns in patients with chronic subdural hematoma: a prospective study. Inflamm Res 2012; 61:845-52. [DOI: 10.1007/s00011-012-0476-0] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2011] [Revised: 03/18/2012] [Accepted: 04/02/2012] [Indexed: 01/05/2023] Open
|