Clinical factors of recurrent chronic subdural hematoma

Clinical Characteristics and Prognoses of Chronic Subdural Hematoma Patients with and without Head Trauma: A Retrospective Comparative Study

OBJECTIVE

Head trauma is considered as the main cause of chronic subdural hematoma (CSDH). However, many patients develop CSDH with no identified cause. Herein, we conduct a comparative study to investigate the differences in clinical characteristics and surgical outcomes of CSDH patients with and without a history of head trauma.

METHODS

We retrospectively reviewed CSDH patients who underwent surgical treatment in our hospital between January 2013 and December 2021. Patients were categorized into a with head trauma (WHT) group and a without head trauma (WOHT) group for comparative analysis.

RESULTS

A total of 219 patients were included, 119 (54.3%) cases in the WHT group and 100 (45.7%) cases in the WOHT group. More cancer patients were found in the WOHT group than in the WHT group (P = 0.045). Both at discharge and 6-month follow-up, patients in the WOHT group achieved better clinical outcomes than the WHT group cases (P = 0.025 and 0.034, respectively). Furthermore, ordered multiclass logistic regression analyses indicated that a history of head trauma (odds ratio 2.151, 95% confidence interval 1.052-4.386; P = 0.036) was a risk factor significantly related to the unfavorable outcomes at 6-month follow-ups of CSDH. However, we did not find significant differences between the 2 groups in clinical manifestations, radiological characteristics, postoperative complications, mortality, and recurrence rates.

CONCLUSIONS

CSDH patients with a history of head trauma may be more susceptible to unfavorable outcomes; thus, they should be carefully evaluated and given more attention during hospitalization and after discharge.

Time-of-flight magnetic resonance angiography for detection of postoperative recurrence in patients with chronic subdural hematoma

PURPOSE

Chronic subdural hematoma (CSDH) is associated with postoperative recurrence. Although various factors are involved in postoperative recurrence of CSDH, blood flow, especially in the middle meningeal artery (MMA), is considered to play an important role. We investigated whether the degree of signal intensity (SI) of the MMA on time-of-flight magnetic resonance angiography (TOF MRA) and various clinical factors are involved in recurrence of CSDH.

METHODS

The maximum SI of both MMAs was measured on TOF MRA images within 1 month before or after the initial surgery.

RESULTS

In total, 185 patients (20 with and 165 without recurrence of CSDH) were included in the analysis. The SI ratio and dementia were significant predictors of recurrence of CSDH (SI ratio: odds ratio [95% confidence interval (CI)] = 1.71 [1.32, 2.22], p < 0.0001; dementia: odds ratio [95% CI] = 7.41 [1.83, 30.1], p = 0.005). The estimated regression coefficients in the final model were 6.14 for the SI ratio and 1.28 for dementia. The risk score was derived according to these regression coefficients as follows: score = 5 × SI ratio + 1 (dementia: yes). With a score of 5, the predicted probability of recurrence was 2% [95% CI 0.7, 5.7], whereas with scores of 8 and 10, the probability was 43.3% [27.0, 61.1] and 89.5% [65.7, 97.5], respectively, which increased the risk of recurrence.

CONCLUSION

Patients with an increased SI ratio of the affected MMA on TOF MRA who underwent surgery for CSDH were significantly more likely to experience recurrence.

Outcome of Chronic Subdural Hematoma Intervention in Patients on Long-Term Antiplatelet Therapy-A Propensity Score Matched Analysis

BACKGROUND

Patients presenting with chronic subdural hematomas (cSDHs) and on antiplatelet medications for various medical conditions often complicate surgical decision making.

OBJECTIVE

To evaluate risks of preprocedural and postprocedural antiplatelet use in patients with cSDHs.

METHODS

Patients with cSDH who were treated between January 2006 and February 2022 at a single institution with surgical intervention were identified. A propensity score matching analysis was then performed analyzing length of hospitalization, periprocedural complications, reintervention rate, rebleeding risk, and reintervention rates.

RESULTS

Preintervention, 178 patients were on long-term antiplatelet medication and 298 were not on any form of antiplatelet. Sixty matched pairs were included in the propensity score analysis. Postintervention, 88 patients were resumed on antiplatelet medication, whereas 388 patients did not have resumption of antiplatelets. Fifty-five pairs of matched patients were included in the postintervention propensity score analysis. No significant differences were found in length of hospitalization (7.8 ± 4.2 vs 6.8 ± 5.4, P = .25), procedural complications (3.3% vs 6.7%, P = .68), or reintervention during the same admission (3.3% vs 5%, P = 1). No significant differences were seen in recurrence rate (9.1% vs 10.9%, P = 1) or reintervention rate after discharge (7.3% vs 9.1%, P = 1) in the postintervention group.

CONCLUSION

Preintervention antiplatelet medications before cSDH treatment do not affect length of hospitalization, periprocedural complications, or reintervention. Resumption of antiplatelet medication after cSDH procedures does not increase the rebleeding risk or reintervention rate.

Factors Associated With Short-Term Outcomes of Burr-Hole Craniostomy Associated With Brain Re-Expansion and Subdural Hematoma Shrinkage for Chronic Subdural Hematoma

Objective

Chronic subdural hematoma (CSDH) is a commonly encountered neurosurgical pathology that frequently requires surgical intervention. With an increasingly aging demographic, more older people and patients with comorbidities will present with symptomatic CSDH. This study evaluated clinical and laboratory factors affecting the short-term outcomes of CSDH after surgical intervention.

Methods

We retrospectively analyzed 170 patients who underwent burr-hole trephination for CSDH in a single institution from January 2019 to December 2021. All patients were examined for risk factors and evaluated for hematoma thickness change and midline shifting on brain computed tomography (CT) scans at 3 days after burr-hole trephination.

Results

This consecutive series of patients included 114 males (67.1%) and 56 females (32.9%); mean age 72.4±12.5 years. Renal disease (p=0.044) and prior intracranial hemorrhage (p=0.004) were clinical factors associated with poorer prognosis. A statistically significant association was found between initial laboratory findings, including high creatine kinase (p=0.025) and low platelet (p=0.036) levels, and CT findings 3 days postoperatively. The 3-day mean arterial pressure and postoperative ambulation were not significantly associated with outcomes.

Conclusion

Burr-hole craniostomy is an effective surgical procedure for initial CSDH. However, patients with a history intracranial hemorrhage and abnormal laboratory findings, such as low platelet levels, who underwent burr-hole trephination had poor short-term outcomes. Therefore, these patients should be carefully monitored.

Recurrent Subdural Hematoma: An Institutional Experience

Background Chronic subdural hematoma (CSDH) is a common neurosurgical problem, which offers a good outcome following surgery. In many cases, burr hole irrigation and drainage under local anesthesia can provide satisfactory results. However, recurrence can be a cause for concern for both the surgeon and the patient. While recurrence is not a frequent phenomenon, studies have reported rates of up to 31.6%. Aims and objectives In this study, our objective is to examine a comprehensive range of potential risk factors and provide valuable insights into identifying patients at a higher risk of recurrence to aid in surgical decision-making. Methodology This study employed a prospective and retrospective design, conducted between 2017 and 2021, at Sri Ramachandra Institute of Higher Education and Research. The study received ethical approval from the Institutional Ethics Committee. The research aimed to assess patients who underwent surgery for CSDH, with a particular focus on those who experienced recurrence. Results The average age of patients with recurrence was 71.5 years compared to 65.2 years in the no-recurrence group, but this difference did not show a significant statistical correlation. A significant male predominance was observed, with 27 men and four women affected (out of a total of 147 men and 73 women in the study), resulting in a statistically significant p-value of 0.01. On multivariate analysis, heterogenous subtypes were a significant predictor of recurrence (OR: 8.88, 95% CI: 6.96-16.54, p = 0.01). The mean midline shift in those with recurrence was 11.4 mm compared to 7.09 mm in those without recurrence. This was a statistically significant correlation with a p-value of 0.02. Regarding those with recurrence, 24 patients underwent evacuation using two burr holes, with one placed in the frontal region and another in the parietal region. All of these patients had a subdural drain placed, which was removed on postoperative day 2. The remaining eight patients underwent a mini-craniotomy for evacuation. We had four cases of refractory CSDH, all of whom underwent the second evacuation using burr holes. Three of them underwent evacuation via craniotomy, while the family of the fourth patient did not give consent for the procedure. Conclusion Patient-related factors such as gender, bilateral presentation, and the presence of hypertension and radiological factors such as the presence of heterogenous subtype and a significant midline shift are clues toward a higher chance of recurrence.

Burr hole locations are associated with recurrence in single burr hole drainage surgery for chronic subdural hematoma

Background

Various factors have been reported as risk factors for chronic subdural hematomas (CSDH) recurrence. However, few studies have quantitatively evaluated the impact of CSDH locations and burr hole positions on recurrence. This study aimed to reveal the relation between CSDH recurrence and the locations of CSDH and burr holes.

Methods

Initial single burr hole surgeries for CSDH with a drainage tube between April 2005 and October 2021 at Otemae Hospital were enrolled. Patients' medical records, CSDH volume, and CSDH computed tomography values (CTV) were evaluated. The locations of CSDH and burr holes were assessed using Montreal Neurological Institute coordinates.

Results

A total of 223 patients were enrolled, including 34 patients with bilateral CSDH, resulting in 257 surgeries investigated. The rate of CSDH recurrence requiring reoperation (RrR) was 13.5%. The RrR rate was significantly higher in patients aged ≥76 years, those with bilateral CSDH, and those with postoperative hemiplegia. In RrR, the preoperative CSDH volume was significantly larger, and CTV was significantly smaller. The locations of CSDH had no influence on recurrence. However, in RrR, the locations of burr holes were found to be more lateral and more ventral. Multivariate Cox proportional hazards regression analysis showed that bilateral CSDH, more ventral burr hole positions, and postoperative hemiplegia were risk factors for recurrence.

Conclusions

The locations of burr holes are associated with CSDH recurrence. In RrR, CSDH profiles tend to show a larger volume and reduced CTV. Hemiplegia after burr hole surgery serves as a warning sign for RrR.

A low prognostic nutritional index is associated with chronic subdural hematoma recurrence

Chronic subdural hematoma (CSDH) is a common neurosurgical condition. Inflammation has been found to play an essential role in the formation of CSDHs, and the prognostic nutritional index (PNI), a nutritional and inflammatory baseline marker, plays a role in predicting the prognosis of many diseases. We aimed to identify the relationship between PNI and CSDH recurrence. This study retrospectively analyzed 261 CSDH patients who underwent burr hole evacuation in Beijing Tiantan Hospital from August 2013 to March 2018. The PNI was calculated as 5 ∗ lymphocyte count (10⁹/L) + serum albumin concentration (g/L), and these markers were obtained from the peripheral blood test on the day of discharge from the hospital. Recurrence was defined as operated hematoma enlargement accompanied by newly emerging neurological disorders. The comparison of baseline characteristics demonstrated that patients with bilateral hematoma and low levels of albumin, lymphocytes, and PNI were more likely to be recurrent. After adjusting for age, sex, and other important variables, decreased PNI levels were associated with an increased risk of CSDH (OR, 0.803, 95% CI: 0.715-0.902, p = 0.001). The addition of PNI to conventional risk factors significantly improved the risk prediction of CSDH (net reclassification index: 71.12%, p = 0.001; integrated discrimination index: 10.94%, p = 0.006). A low PNI level is associated with an increased risk of CSDH recurrence. As an easily obtainable nutritional and inflammatory marker, PNI may play a significant role in predicting the recurrence of CSDH patients.

Clinical Outcome and Recurrence Risk of Chronic Subdural Hematoma After Surgical Drainage

Introduction Chronic subdural hematoma (CSDH) is one of the most encountered neurosurgical cases. CSDH is defined as the accumulation of liquified blood products in the space between the dura and the arachnoid. A reported incidence of 17.6/100,000/year has more than doubled in the past 25 years in parallel with an aging population. Surgical drainage remains the mainstay of treatment, yet it is challenged by variable recurrence risks. Less invasive embolization methods of the middle meningeal artery (EMMA) could reduce the recurrence risks. Before adopting a newer treatment (EMMA), it is prudent to establish the outcomes from surgical drainage. The purpose of this study is to assess the clinical outcome and recurrence risk in surgically treated CSDH patients in our center. Methods A retrospective search of our surgical database was done to identify CSDH patients undergoing surgical drainage in the year 2019-2020. Demographic and clinical details were collected, and quantitative statistical analysis was performed. Peri-procedural radiographic information and follow-ups were also included as per the standard of care. Results A total of 102 patients (mean age: 69 years; range: 21-100 years; male: 79) with CSDH underwent surgical drainage with repeat surgery in 13.7% of the patients (n=14). Peri-procedural mortality and morbidity were 11.8%(n=12) and 19.6% (n=20), respectively. Overall, among our patient population, recurrence was seen in 22.55% (n=23). The mean total hospital stay was 10.6 days. Conclusions Our retrospective cohort study showed an institutional CSDH recurrence risk of 22.55%, in keeping with what is reported in the literature. This baseline information is important for a Canadian setting and provides a basis for comparison for future Canadian trials.

Postoperative pneumocephalus and recurrence and outcome of chronic subdural hematoma: a systematic review and meta-analysis

We conducted a meta-analysis to analyze the effects of pneumocephalus after chronic subdural hematoma (CSDH) surgery on hematoma recurrence, mortality, and functional outcomes. In this meta-analysis, following PRISMA guidelines, PubMed, Embase, Cochrane Library, and Web of Science online databases were queried using the keywords "pneumocephalus," "pneumoencephalos," "intracranial pneumatocele," "pneumo encephalon," "subdural air," and "chronic subdural hematoma." The results were limited to English-language articles. Through the online database, we identified a total of 276 articles and finally included 14 articles for meta-analysis. The results showed that the recurrence rate in the pneumocephalus group was higher than that in the control group, with a pooled OR of 3.35 (CI: 2.51-4.46, P < 0.001). There was no difference in recurrence rate between the no/few and moderate pneumocephalus groups (OR: 1.27, CI: 0.68-2.37, P = 0.46), but the recurrence rate of the large pneumocephalus group was significantly higher than that of the moderate group, with a pooled OR of 3.29 (CI: 1.71-6.32, P < 0.001). This study failed to show higher mortality and worse outcomes in the pneumocephalus group than in the control. Pneumocephalus after surgical evacuation of CSDH was associated with the recurrence rate of hematoma. Pneumocephalus affecting recurrence was correlated with gas volume, and moderate pneumocephalus may have less impact, while patients with large pneumocephalus are more likely to recur than those with moderate pneumocephalus. More prospective cohort studies are needed for further investigation and verification. This meta-analysis was registered (PROSPERO CRD42022321800).

Homogeneous Chronic Subdural Hematoma with Diverse Recurrent Possibilities

Background: Evidence suggests that hyperdense (HD) chronic subdural hematomas (CSDHs) have a higher recurrence than hypodense (LD) chronic subdural hematomas. The value of mean hematoma density (MHD) has been proven to be associated with postoperative recurrence. The MHD levels in homogeneous CSDHs likely underestimate the risk of recurrence in HD homogeneous subtypes. Methods: This study investigated 42 consecutive CSDH cases between July 2010 and July 2014. The area of the hematoma was quantified to determine the MHD level using computer-based image analysis of preoperative brain CT scans. Results: In terms of the MHD distribution of the four types of CSDHs (homogeneous, laminar, separated, and trabecular), wide 95% CI (11.80-16.88) and high standard deviation (4.59) can be found in homogeneous types, reflecting a high variability in the MHD levels between cases (from low to high density). The categorization of homogeneous types into LD and HD (type five) displayed a minor standard deviation in the MHD levels for LD and HD subtypes (1.15, and 0.88, respectively). MHD values demonstrated concentrated distributions among the respective five types, compared to the four-type setting. Conclusions: In the current research, we provide a consideration that if LD and HD hematomas are separated from homogeneous CSDHs, the variability of the MHD quantification can potentially be reduced, thereby avoiding the possibility of undetected high-risk groups.

Clinical and Radiological Characteristics for Recurrence of Chronic Subdural Hematoma: A Systematic Review and Meta-Analysis

Chronic subdural hematoma (cSDH) is one of the most studied clinical entities in the neurosurgical literature. Management of cSDH is complicated by its propensity to recurrence. Various factors for the development of recurrence of cSDH have been described in various clinical, epidemiological, and observational studies, yet the evidence available is limited. A systematic review and meta-analysis as per PRISMA guidelines to identify clinical and radiological factors which can predict the development of recurrence in cSDH. A total of 14 studies were included for the systematic review and meta-analysis after a comprehensive search of the online databases. Eight studies were of high methodological quality. Age, use of anticoagulants, obesity, seizure, and liver disease were found to be statistically significant clinical risk factors for the development of recurrence in cSDH. Among the radiological parameters, the internal structure of the hematoma and the width of the hematoma was found to be significant risk factor predicting the development of recurrence. Age >75 years, use of anticoagulation therapy, liver disease, and obesity were significant risk factors for cSDH recurrence. Pneumocephalus, internal architecture of hematoma, bilateral cSDH, the width of hematoma, and the presence of bilateral cSDH are important radiological parameters of the development of recurrent cSDH

Hematoma cavity separation and neomembrane thickness are potential triggers of recurrence of chronic subdural hematoma

Background

Chronic subdural hematoma (CSDH) is the anomalous and encapsulated accumulation of fluid of complex origin consisting of old blood, mostly or totally liquified and cerebrospinal fluid (CSF) in the subdural space usually after a head injury in the elderly. Almost all the research on surgical techniques and endoscopic assisted evacuation of CSDH focused on the just the evacuation and not abnormal anatomical structures that causes recurrences.

Objectives

We investigated abnormal anatomical structures that triggers recurrence of CSDH during craniotomy as well as burr-hole craniostomy with endoscopic assistance.

Materials and methods

We retrospectively analyzed all patients with CSDH who underwent craniostomy and burr-hole craniotomy with endoscopic assisted evacuation of hematoma between April 2017 and November 2020 at our institution. Clinical data obtained was categorized into patient-related, radiology as well as surgery and endoscopic evaluations.

Results

A total of 143 patients (109 men and 34 women) aged 43–94 years (mean age, 68.35 years) with CSDH were included in this study. We observed a recurrence rate of 4.9% (7/143). Recurrences occurred between 2 and 6 months after the operation in patients with recurrences. Our data revealed that, age, hypertension, history of injury, diabetes, antiplatelet or anticoagulant use were not associated with hematoma recurrence. Nevertheless, all the patients with recurrence of hematoma were males. Interestingly, our univariate and multivariate analyses found neomembrane thickness and hematoma cavity separation as independent risk factors (OR,45.822; 95% CI,2.666-787.711; p = 0.008) for the recurrence of CSDH (p < 0.05). Also, we observed thickened membranes connecting/separating the dura and the thickened arachnoid/pia matters in all the 7 patients with hematoma recurrence.

Conclusions

The treatment of patients with CSDH ought to include the identification and resection of abnormal thickened membranes connecting/separating the dura and the thickened arachnoid/pia matters to avoid recurrence. Comparatively, endoscopy showed hematoma cavity separation or neomembrane thickness just as seen during craniotomy.

A Radiological Assessment of Chronic Subdural Hematomas

Chronic subdural hematoma (CSDH), which generally occurs in elderly patients, is a frequently diagnosed condition in neurosurgical departments. Computed tomography (CT) and magnetic resonance imaging (MRI) are the most preferred diagnostic modalities for CSDH assessment. With early diagnosis and adequate management, CSDH may show favorable prognosis in majority of the patients; however, recurrence after surgery can occur in a significant number of patients. The recently increasing number of CSDH studies could reveal the prognostic factors affecting CSDH recurrence. Particularly, radiological characteristics regarding the internal architecture of CSDH are considered closely associated with recurrence in surgically treated CSDH patients. In this literature review, we evaluated the various diagnostic modalities of CSDH and its radiological characteristics on CT and MRI. Furthermore, we summarized the prognostic factors of recurrence for the hematoma type based on the radiological findings.

Surgical management of chronic subdural hematomas through single-burr hole craniostomy: is it sufficient?

Background

Symptomatic chronic subdural hematomas (CSDH) remain one of the most encountered forms of intracranial hemorrhages particularly in the elder patients, yet fortunately implies a good surgical prognosis. Burr hole evacuation under general anesthesia is the most commonly used neurosurgical technique for the management of CSDH. Clinical disagreement between many studies regarding the number of burr holes required to achieve the optimal surgical and clinical outcome has long existed. The objective of this study is to evaluate the prognosis and clinical outcome following the use of single-burr hole craniostomy technique in the aim of surgical evacuation of CSDH.

Results

This is a retrospective study of 30 patients, with symptomatic unilateral or bilateral CSDH managed by the authors strictly by single-burr hole evacuation with closed-system drainage on the corresponding site of the hematoma. Clinical outcome was then assessed at 1, 7, and 30 days after surgery using the Glasgow Coma Scale (GCS) and by comparing the Markwalder grade scale before surgery to 1 month following surgery; the pre- and post-operative radiological data, clinical neurological progress and the possible incidence of complications postoperatively were also recorded. Study duration was from August 2019 to October 2020. Our study included 18 (60%) male patients and 12 (40%) female patients. The main presenting symptom was altered level of consciousness noted in 29 (96.7%) patients; a history of a relevant head trauma was recorded in 11 patients (36.7%). The GCS showed a statistically highly significant improvement comparing the preoperative to the postoperative values throughout the follow-up intervals (p = 0.001); similarly, the Markwalder score significantly improved 1 month after surgery, where 17 (63%) patients were Markwalder grade 0, 9(33.3%) patients were grade 1, a single patient (3.7%) was grade 2, and none were Markwalder grade 3.

Conclusion

Our study concluded that single-burr hole craniostomy with closed-system drainage for the management of symptomatic CSDH would be a sufficient approach to achieve a good surgical outcome with a low complication rate. Larger series and further studies would be yet considered with longer follow-up periods.

Comparative study of subdural drain (SDD) versus sub periosteal drain (SPD) in treating patient with chronic subdural hematoma (CSDH)

Background:

Chronic subdural hematoma (CSDH) is common neurosurgical condition encountered in daily practice. Burr holes evacuation is standard treatment for symptomatic cases. Both subdural drain (SDD) and subperiosteal drain (SPD) have been reported to lower the recurrence rate when used in conjunction with burr holes. A randomized controlled trials were done to see if there were any differences in clinical and radiographic outcomes between the two types of drains.

Methods:

A total of 42 CSDH patients were enrolled and allocated to one of two groups: SDD (n = 21) or SPD (n = 21). Demographic data, perioperative imaging characteristics, clinical outcome, and recurrence rate were recorded for comparison.

Results:

In both groups, demographic characteristics such as sex ratio, mean age of patients, concomitant disease, and antithrombotic agent use were similar. At 6 months, 20 (95.2%) and 21 (100%) cases in the SDD and SPD groups, respectively, had a favorable outcome (mRS 0–3). Complete hematoma resolution at 6 months was achieved in 21 (100%) and 19 (90.5%) cases of the SDD and SPD groups, respectively. The amount of drain within 48 h was not difference between the two groups. None of the SDD recurred, but two of the SPD group did, necessitating reoperation, which had no effect on the final outcome.

Conclusion:

These findings indicate that the drain type (SDD or SPD) has no effect on the outcome. The surgeon’s preference determines which procedure is used. Except in symptomatic circumstances, routine postoperative imaging may not be required.

Hematoma subdural crónico: Una patología común de manejo complejo

Antecedentes:

El hematoma subdural crónico (HSDC) es una patología ampliamente estudiada, muy frecuente, sobre todo en adultos mayores; su cuadro clínico tiene una apariencia benigna y suele ir acompañado de múltiples comorbilidades asociadas a la edad, lo que resulta en un aumento de las complicaciones e incluso la muerte. Con el incremento de la expectativa de vida a nivel mundial, el uso de medicamentos antitrombóticos es cada vez más frecuente. El papel de estos fármacos en la evolución de la enfermedad como en la recurrencia, sigue siendo motivo de discusión.

Métodos:

Los autores revisaron la fisiopatología y características clínicas del HSDC. El presente artículo discute acerca de las terapéuticas actuales y las nuevas opciones de tratamiento que podrían mejorar los resultados. Este manuscrito es susceptible de cambios en el tiempo, con el desarrollo científico y tecnológico.

Resultados:

El HSDC puede ser abordado por vía quirúrgica y farmacológica; no obstante, un manejo individualizado requiere la consideracion cuidadosa de diversos factores. A pesar de los avances en el campo de la neurocirugía, la clásica trepanación craneal sigue siendo el Gold estándar en el HSDC y sobre todo en pacientes con síntomas graves. Se debe resaltar que aún hay aspectos de este procedimiento (como la localización del dren, número de drenajes, el efecto de la irrigación, la temperatura de la solución con que se irriga, etc.) que siguen siendo materia de estudio.

Conclusiones:

Entender el mecanismo de la enfermedad ha permitido explicar su historia natural y a su vez proponer nuevas alternativas de tratamiento. El manejo médico (atorvastatina, corticoides) ha generado gran interés por sus alentadores resultados preliminares. Recientemente, se ha reportado la terapia endovascular como una alternativa segura y existe gran expectativa por confirmar su efecto en estudios más grandes.

Risk of recurrence of subdural hematoma after EMMA vs surgical drainage - Systematic review and meta-analysis

OBJECTIVE

Chronic subdural hematoma (CSDH) is a common and debilitating neurological condition whose treatments, including burr hole drainage and craniotomy, suffer from high rates of recurrence and complication. Embolization of the middle meningeal artery (EMMA) is a promising minimally invasive approach to manage CSDH in a broad set of patients.

METHODS

To evaluate the efficacy and safety of EMMA, a database search was conducted including the terms "subdural hematoma; embolization; embolized; middle meningeal" was performed and yielded a total of 260 results. Following exclusion based on predefined criteria, a total of four studies were identified and outcomes including recurrence rates and complication rates were extracted for analysis.

RESULTS

Four studies including intervention and control groups were included with a total of n = 888 patients. The relative risk of CSDH recurrence in the EMMA (3.5%) compared to control group (23.5%) was significantly reduced when EMMA was performed (risk ratio = 0.17; 95% confidence interval (CI) 0.05-0.67). In addition, rates of complication were not significantly different between patients with conventional therapy and those who received EMMA (OR = 0.77; 95 confidence interval (CI) 0.3-1.99).

CONCLUSION

Based on limited data, EMMA reduces the risk of recurrence by 20% compared to surgical treatment for CSDH.

Efficacy of the Direct Aspiration-Irrigation Maneuver for the Treatment of Chronic Subdural Hematoma: A Single Hospital's Experience

Objective The traditional methods for managing symptomatic chronic subdural hematoma (CSDH) at our hospital include evacuation via single burr-hole irrigation with continuous closed subdural drainage (SBID). The single burr-hole aspiration and irrigation technique with continuous closed subdural drainage (SBAID) is an attractive alternative method. The goal of this study was to evaluate the radiographic and clinical outcomes of SBAID compared with traditional SBID methods. Methods A database of 51 CSDH patients treated with the SBAID method and 35 CSDH patients treated with the SBID method was compiled, and a retrospective chart review was performed. Information regarding demographics, comorbidities, presenting symptoms, and outcomes were collected. Predictors of recurrence requiring reoperation and other outcomes were analyzed. Results Compared to the patients in the SBID group, the patients in the SBAID group had a shorter mean duration of surgery (56.6±5.6 minutes vs 59.5±4.8 minutes, respectively, P=0.02); a shorter mean interval from procedure to discharge (6.2±1.2 days vs 6.8±1.3 days, respectively, P=0.046); no significant difference in preoperative hematoma volume (106.4±21.7 cm³ vs 101.3±16.3 cm³, respectively, P=0.25); and a smaller subdural space volume 48 hours after the operation (43.6±7.4 cm³ vs 47.4±9.1 cm³, respectively, P=0.03). In addition, symptomatic hematoma recurrence developed in one patient in the SBAID group and five patients in the SBID group (P=0.03). The in-hospital mortality rates of the SBAID and SBID groups were 2% (1 of 51) and 6% (2 of 35), respectively; this difference was not statistically significant (P=0.35). Conclusions The SBAID method results in a remarkably low recurrence rate and good outcomes. This method should be considered for patients presenting with symptomatic CSDHs.

Recurrent Spontaneous Bilateral Subdural Hemorrhage as a Consequence of High-Cervical Spontaneous CSF Leak—Lessons for Neurosurgeons

Spontaneous intracranial hypotension (SIH) is rare. It presents as intractable posture headache and is identified by radiological findings. It is confirmed by cerebrospinal fluid (CSF) manometry and myelography, and treatment is carried out with the help of epidural blood patch (EBP) therapy. SIH presenting with spontaneous bilateral recurrent subdural bleeds is uncommon. The cause being a high-spinal CSF leak is even more uncommon! Our patient had recurrent bilateral spontaneous chronic subdural hematomas. Myelographic examination of the spine showed a C1–C2 level leak of CSF. He was taken up for open microsurgery, and the leak was identified and closed with fibrin glue. The patient however deteriorated the next day. An EBP was applied in the lumbar region to cover the myelogram lumbar puncture site. We present a review of literature and an algorithm to detect the elusive CSF leak and effect definitive treatment, either open or EBP, to treat the source of the problem.

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

Introduction

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

Research question

What is the state of the art of cSDH management.

Material and methods

Review.

Results

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

Discussion and conclusion

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

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

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cSDH occurs bilaterally in 9–22% of cases.

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

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Risk factors for recurrence include old age and bilateral cSDHs.

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

A Comparative Study of Chronic Subdural Hematoma in Patients With and Without Head Trauma: A Retrospective Cross Sectional Study

Background: The clinical features of chronic subdural hematomas (CSDHs) in patients with and without a history of head trauma have remained unclear. Here, we investigated differences in clinical characteristics in CSDH patients with and without head trauma. Methods: We retrospectively collected clinical characteristics of CSDH patients who had undergone exhaustive drainage strategies via burr-hole craniostomies from August 2011 to May 2019. We divided patients into a trauma group (i.e., head trauma) and a no-trauma group. Chi-square tests or t-tests were used to analyze differences in clinical characteristics between the two groups. Multiple linear regression analysis was performed to analyze the relationships between the clinical characteristics and either reduction of the hematoma cavity or length of the hospital stay in CSDH patients with trauma. Results: We collected data from 1,307 CSDH patients, among whom 805 patients had a history of head trauma whereas 502 patients did not. The mean age of patients with head trauma was 64.0 ± 16.1 years, while that of patients without head trauma was significantly younger at 61.5 ± 17.9 years (p = 0.010). Furthermore, more patients in the no-trauma group had a history of hypertension compared to those in the trauma group (40.2 vs. 32.9%, p = 0.007). Dizziness occurred in 29.2% of patients with trauma and in 23.1% of patients without trauma (p = 0.016). A greater number of patients with trauma showed a reduction of hematoma cavity after surgery compared to that of patients without trauma (p = 0.002). The length of hospital stay in patients with trauma was 7.9 ± 4.5 days, which was longer than that of patients without trauma (7.3 ± 3.7 days, p = 0.016). In contrast, there were no significant different differences between the two groups in terms of the densities of hematomas on computed-tomography scans, complications, mortality rates, recurrence rates, or outcomes. Conclusion: Our findings indicate that there were some noteworthy differences in the clinical and pathogenic characteristics of CSDH patients with and without head trauma. However, our findings also indicate that if an optimal treatment method is employed, such as our exhaustive drainage strategy, similar treatment outcomes can be achieved between these groups.

Radiological prognostic factors of chronic subdural hematoma recurrence: a systematic review and meta-analysis

Purpose

Chronic subdural hematoma (CSDH) is associated with high recurrence rates. Radiographic prognostic factors may identify patients who are prone for recurrence and who might benefit further optimization of therapy. In this meta-analysis, we systematically evaluated pre-operative radiological prognostic factors of recurrence after surgery.

Methods

Electronic databases were searched until September 2020 for relevant publications. Studies reporting on CSDH recurrence in symptomatic CSDH patients with only surgical treatment were included. Random or fixed effects meta-analysis was used depending on statistical heterogeneity.

Results

Twenty-two studies were identified with a total of 5566 patients (mean age 69 years) with recurrence occurring in 801 patients (14.4%). Hyperdense components (hyperdense homogeneous and mixed density) were the strongest prognostic factor of recurrence (pooled RR 2.83, 95% CI 1.69–4.73). Laminar and separated architecture types also revealed higher recurrence rates (RR 1.37, 95% CI 1.04–1.80 and RR 1.76 95% CI 1.38–2.16, respectively). Hematoma thickness and midline shift above predefined cut-off values (10 mm and 20 mm) were associated with an increased recurrence rate (RR 1.79, 95% CI 1.45–2.21 and RR 1.38, 95% CI 1.11–1.73, respectively). Bilateral CSDH was also associated with an increased recurrence risk (RR 1.34, 95% CI 0.98–1.84).

Limitations

Limitations were no adjustments for confounders and variable data heterogeneity. Clinical factors could also be predictive of recurrence but are beyond the scope of this study.

Conclusions

Hyperdense hematoma components were the strongest prognostic factor of recurrence after surgery. Awareness of these findings allows for individual risk assessment and might prompt clinicians to tailor treatment measures.

Subdural Drain versus Subdural Evacuating Port System for the Treatment of Nonacute Subdural Hematomas: A Single-Center Retrospective Cohort Study

BACKGROUND

Subdural drain (SDD) and Subdural Evacuating Port System (SEPS) are bedside options for management of nonacute subdural hematomas (SDHs). These interventions have not been compared with each other. Our objective is to compare the need for second bedside procedure, need for craniotomy, complication rate, and other outcomes related to bedside drainage of SDH with SDD or SEPS. We hypothesized that SDD would be associated with superior outcomes to SEPS.

METHODS

Database queries and direct patient chart reviews were used to gather patient data. t-Tests, Fisher exact tests, and proportional odds models were performed.

RESULTS

Of 41 SDDs and 25 SEPS, baseline characteristics were similar except more isodense SDHs were present in SDD (P = 0.0312). SEPS was associated with significant risk of requiring a second bedside procedure (odds ratio, 3.2381; 99% confidence interval, 1.0345-10.1355) relative to SDD. Need for craniotomy did not differ between groups (12.1% SDD vs. 16% SEPS; P = 0.721). The complication rate was similar between groups (2.4% SDD vs. 12% SEPS; P = 0.1484). Symptom resolution, condition at latest follow-up, and posthospital disposition were similar between groups, but SEPS was associated with longer intensive care unit and total hospital length of stay (P = 0.02 and 0.04, respectively).

CONCLUSIONS

SEPS was associated with higher risk for need of second bedside procedure and longer intensive care unit and hospital length of stay than SDD, although not increased need for craniotomy. Additional studies are needed to confirm our findings and determine if SDD may be more effective than SEPS for the treatment of nonacute SDH.

Critical Depressed Brain Volume Influences the Recurrence of Chronic Subdural Hematoma after Surgical Evacuation

Recurrence of chronic subdural hematoma (CSDH) frequently occurs after surgical evacuation. However, the value of follow-up postoperative imaging and measuring volumetric factors to predict recurrence are still controversial. Herein, we aimed to assess the optimal timing for follow-up referential imaging and the critical depressed brain volume for CSDH recurrence. A total of 291 patients with CSDH who underwent burr hole craniotomy between January 2012 and December 2018 were consecutively enrolled in this study. Patients’ medical records and radiologic data were evaluated to predict the recurrence and analyzed using receiver operating characteristics (ROC) and binary logistic regression. Of the 291 patients, 29 (10.0%) showed recurrence after surgical evacuation. Based on ROC analysis, comparisons of depressed brain volume pre-operation, 24 h post-operation, and 7 days post-operation showed that the depressed brain volume at 7 days after surgery featured the largest area under the curve (AUC: 0.768, 95% CI, 0.709–0.811). The cut-off value of the depressed brain volume on postoperative day 7 was 51.6 cm³; this value predicted the recurrence of CSDH with a sensitivity and specificity of 79.3% and 67.9%, respectively. In the multivariate analysis, the depressed brain volume (>50 cm³) at 7 days was the sole significant risk factor related to the recurrence of CSDH in this series (OR: 6.765, 95% CI, 2.551–17.942, p < 0.001). The depressed brain volume > 50 cm³ visualized on CT scans at postoperative 7 day is the critical volume affecting recurrence of CSDHs. This result could be helpful carrying in patients with CSDH to determine the proper postoperative treatment strategy.

Predicting Chronic Subdural Hematoma Recurrence and Stroke Outcomes While Withholding Antiplatelet and Anticoagulant Agents

Introduction: The aging of the western population and the increased use of oral anticoagulation (OAC) and antiplatelet drugs (APD) will result in a clinical dilemma on how to balance the recurrence risk of chronic subdural hematoma (cSDH) with the risk of withholding blood thinners.

Objective: To identify features that predicts recurrence, thromboembolism (TEE), hospital stay and mortality. To identify the optimal window for resuming APD or OAC.

Methods: We performed a retrospective multivariate analysis of a prospectively collected database. We then build machine learning models for outcomes prediction.

Results: We identified 596 patients. The rate of recurrence was 22.17%, that of thromboembolism was 0.9% and that of mortality was 14.78%. Smoking, platelet dysfunction, CKD, and alcohol use were independent predictors of higher recurrence, while resolution of the SDH was protective. OAC use had higher odds of developing TEEs. CKD, developing a new neurological deficit or a TEEs were independent predictors of higher mortality. We find the optimal time of resuming OAC to be after 2 days but before 21 days as these patients had the lowest recurrence of bleeding associated with a low risk of stroke. The ML model achieved an accuracy of 93, precision of 0.84 and recall of 0.80 for recurrence prediction. ML models for hospital stay performed poorly (R² = 0.33). ML model for stroke was overfitted given the low number of events.

Conclusion: ML modeling is feasible. However, large well-designed prospective multicenter studies are needed for accurate ML so that clinicians can balance the risks of recurrence with the risk of TEEs, especially for high-risk anticoagulated patients.

Prediction of postoperative recurrence of chronic subdural hematoma using quantitative volumetric analysis in conjunction with computed tomography texture analysis

Chronic subdural hematoma (CSDH) is a common disease in older individuals with a substantial rate of recurrence. The mechanism of CSDH recurrence remains unclear. This study aimed to detect imaging parameters that could indicate the risk for CSDH recurrence by using quantitative volumetric analysis and computed tomography (CT) texture analysis (CTTA). Clinical and imaging parameters were retrospectively investigated in 147 newly diagnosed CSDH lesions in 114 patients surgically treated at the Keio University Hospital during a 6-year period. For CT images, quantitative volumetric and texture analyses were performed. Hematoma volume, postoperative air volume, hematoma density, and texture parameters including kurtosis, skewness, and entropy were evaluated and compared with CSDH recurrence rate. Data were statistically evaluated, and a difference of p < 0.05 was considered significant. Reoperation for CSDH recurrence was required in 27 sides (18.4%) of 26 patients. Multivariate analysis showed that postoperative hematoma volume and postoperative hematoma density were independent risk factors for symptomatic CSDH recurrence that required reoperation. Postoperative hematoma volume, postoperative significant residual air, and postoperative hematoma density were also identified as independent risk factors for potential CSDH recurrence. Preoperative hematoma entropy was prone to be associated with both symptomatic and potential CSDH recurrence in univariate analysis, but not in multivariate analysis because of confounding factors. Quantitative volumetric analysis and CTTA could aid in distinguishing individuals at risk for CSDH recurrence.

Feasibility and Safety of Endoscopic Procedure in Burr-Hole Surgery for Chronic Subdural Hematoma in Patients of Very Advanced Age

OBJECTIVE

The usefulness of endoscopic procedures for chronic subdural hematoma (CSDH) has been described, but the indications in patients of very advanced age have not been analyzed. The aim of this study was to evaluate the feasibility, safety, and usefulness of introduction of an endoscopic procedure for such patients.

METHODS

We retrospectively analyzed the data of 540 CSDHs treated by burr-hole surgery with endoscopic examination. The safety of the endoscopic procedure was assessed according to postoperative complications, morbidity, and mortality. The outcome was evaluated by statistical comparison among 4 different age-groups, and the recurrence rate and risk factors for recurrence was investigated in patients of very advanced age.

RESULTS

Postoperative complications occurred in 7 cases (1.5%). The 6-month morbidity and mortality were 13.5% and 4.5%. No complications, morbidity, or mortality associated with the additional endoscopic procedure occurred even in patients of very advanced age. The endoscopic features of trabecular structures and residual septa separating the cavity were also risk factors for recurrence in patients of very advanced age. Releasing of the septa showed the possibility of decreasing the risk of recurrence to 6.6% in patients aged ≥85 years as well as in younger patients. There were some inevitable problems such as prolongation of the surgical time and inadequate endoscopic surgical skill.

CONCLUSIONS

An endoscopic procedure for CSDH can be safely indicated and useful even in patients aged ≥85 years. However, clinicians should carefully select the patients based on clinical information associated with risk factors for recurrence.

Burr Hole Drainage versus Small Craniotomy of Chronic Subdural Hematomas

Objective

Chronic subdural hematoma drainage is one of the most common procedures performed in neurosurgical practice. Not only burr hole drainage but also small craniotomy (diameter 3–5 cm) is frequently used neurosurgical treatment of chronic subdural hematomas. We assessed to compare the postoperative recurrence rates between burr hole drainage versus small craniotomy with closed-system drainage for chronic subdural hematomas.

Methods

From January 2016 to December 2018, 75 patients who were treated with burr hole drainage and small craniotomy with closed system drainage for the symptomatic chronic subdural hematoma were enrolled. Pre and postoperative computed tomography (CT) were used for radiologic evaluation. The choice of procedure was decided by preoperative CT images.

Results

60 patients out of 75 patients underwent burr hole drainage, whereas 15 patients underwent small craniotomy. The overall postoperative recurrence rate was 16%. The recurrence occurred in 8 patients out of 60 patients in burr hole drainage group (13.3%) and 7 patients out of 15 patients in small craniotomy group (46.7%). The number of days of hospitalization was 10.3 days in burr hole drainage group and 15.7 days in small craniotomy group.

Conclusion

Burr hole drainage would be sufficient to evacuate chronic subdural hematoma with lower recurrence rate, but small craniotomy was also needed in some cases such as hematoma has solid portion or multiple septum.

Clinical and radiological factors predicting recurrence of chronic subdural hematoma: A retrospective cohort study

BACKGROUND

Chronic subdural hematoma (CSDH) is commonly encountered in the elderly patients and the recurrence rate is still high, therefore, identifying risk factors for CSDH recurrence is essential. The present study aimed to identify clinical and radiological factors predicting the recurrence of CSDH.

METHODS

We retrospectively identified 461 patients with CSDH who underwent surgical evacuation in our department. Univariable analyses were performed at first, variables with a P-value of <0.05 were entered into multivariable logistic regression model. Kendall's tau-b test was used to evaluate the relationship between brain atrophy and postoperative pneumocephalus.

RESULTS

Univariable analyses revealed that patients with the following characteristics have a higher recurrence rate, including age ≥80 years, antiplatelet and/or anticoagulant use, GOS = 3, the volume of drainage ≥100 ml, midline shift ≥10 mm, severe brain atrophy, severe postoperative pneumocephalus. Multivariable logistic regression demonstrated that midline shift ≥10 mm, severe brain atrophy, severe postoperative pneumocephalus, and volume of drainage ≥100 ml were independent risk factors for CSDH recurrence. Kendall's tau-b test revealed that there was no correlation between brain atrophy and postoperative pneumocephalus.

CONCLUSIONS

Midline shift ≥10 mm, severe brain atrophy, severe postoperative pneumocephalus, and volume of drainage ≥100 ml were independent risk factors for CSDH recurrence, CSDH patients with these characteristics should be taken precautions of recurrence and a closely follow-up should be carried out.

High-degree centrum semiovale-perivascular spaces are associated with development of subdural fluid in mild traumatic brain injury

Background

Severe centrum semiovale perivascular spaces (CSO-PVSs) are associated with the onset of brain atrophy and dementia. This study explored the relationship between severity of CSO-PVS and development of subdural fluid (SDF) in patients with mild traumatic brain injury (TBI), with the aim of investigating independent radiological risk factors for development of SDF.

Methods

The study cohort comprised 222 patients with a mean age of 51 years (64.0% men) who presented with mild TBI from January 2013 to November 2016. In this study, mild TBI was defined as a Glasgow Coma Scale (GCS) of ≥ 13, Post-Traumatic Amnesia (PTA) of <1 day, and Loss of Consciousness (LOC) of <30 minutes. The severity of CSO-PVS was categorized as low or high-degree.

Results

Among the 222 enrolled patients, 38 (17.1%) and 90 (40.5%) had high-degree PVS in the basal ganglia (BG) and centrum semiovale, respectively. Compared with patients who did not develop SDF, the mean age of patients who developed SDF was significantly higher (47.41 years versus 60.33 years, P < 0.0001). The incidence of de novo SDF was significantly higher in men than in women (77.8% versus 59.5%, P = 0.0151). Patients who showed SDF on brain computed tomography at admission more frequently developed de novo SDF (68.5% versus 38.1%, P < 0.0001). In multivariate logistic regression analysis of risk factors, high-degree CSO-PVS, male sex, initial SDF on admission, and old age were independently associated with development of de novo SDF after mild TBI. In Cox proportional hazards models of risk factors for SDF-development free survival rate, high-degree CSO-PVS, old age, and initial subdural hemorrhage showed statistically significant differences.

Conclusions

Our study might help neurosurgeons determine the frequency of brain CT or the duration of follow-up for patients who present with mild TBI with high-degree CSO-PVS.

Burr-Hole Evacuation of Chronic Subdural Hematoma: Biophysically and Evidence-Based Technique Improvement

Chronic subdural hematoma (CSDH) is one of the most common neurosurgical conditions. Despite ongoing efforts, recurrence and reoperation rates after surgical treatment remain high. We synthesize scientific evidence on the treatment of CSDH with biophysical principles and then propose a simple and effective surgical technique aiming to reduce the recurrence rate. Under local anesthesia, one burr hole is placed in the area above the maximum hematoma thickness. One drain is inserted into the dorsal direction to the deepest point of the hematoma cavity, and a second drain is inserted frontally into the highest point. Next, saline is gently instilled to the dorsal drain to eliminate air from the hematoma cavity through the frontal drain. Once saline has filled the frontal drain, the frontal drain is removed. The dorsal drain is left in situ for 48 h, and the pressure within the cavity may be adapted hydrostatically. We implemented evidence-based conclusions of previous studies and modified the classical burr-hole technique to reduce the recurrence rate. As a result, we developed a straightforward surgical procedure that is possible to perform under local anesthesia, suitable for everyday practice in rural and remote areas while working with limited resources. The novelty of this technique is in the purposeful reduction of postoperative pneumocephalus, a known independent factor of recurrence. Subdural air is eliminated during surgery using a two-drain system. Safety and efficacy of the technique need to be evaluated in future clinical trials.

Risk Factors for Recurrence of Chronic Subdural Hematoma: A Single Center Experience

OBJECTIVE

Chronic subdural hematoma (CSDH) is a common form of intracranial hemorrhage with a substantial recurrence rate. We aimed to investigate the predictive factors for the postsurgical recurrence of CSDH.

METHODS

We retrospectively reviewed the medical records of patients with CSDH who underwent surgery in West China Hospital between January 2012 and June 2018. Univariate and multivariate analyses were performed to identify the relationships between recurrence of CSDH and factors such as age, sex, history of injury, Markwalder grading, computed tomography findings, surgical methods, and outcomes.

RESULTS

A total of 328 patients (281 men and 47 women) aged 22-93 years (mean age, 65.14 ± 13.76 years) were included. Computed tomography findings at admission showed mixed density hematoma in 136 patients, isodensity hematoma in 140, high-density hematoma in 34, and low-density hematoma in 18. The mortality and recurrence rate were 0.30% (1 of 328) and 2.44% (8 of 328), respectively. Six months postoperatively, 327 patients had Markwalder grade 0. Hematoma recurred in 8 patients of which 7 were mixed density hematoma and 1 was isodensity hematoma. Six patients who underwent craniotomy had thickened inner neomembrane that was resected. Univariate and multivariate analyses found mixed density hematoma to be an independent risk factor for the recurrence of CSDH.

CONCLUSIONS

Burr hole craniostomy with irrigation and closed-system drainage is effective for the surgical treatment of CSDH. Mixed density hematoma is an independent predictor for the recurrence of CSDH. Presence of thick inner neomembrane might be the primary cause of CSDH recurrence.

Corticosteroid treatment compared with surgery in chronic subdural hematoma: a systematic review and meta-analysis

BACKGROUND

There is an ongoing debate on the role of corticosteroids in the treatment of chronic subdural hematoma (CSDH). This study aims to evaluate the effectiveness of corticosteroids for the treatment of CSDH compared to surgery.

METHOD

A systematic search was performed in relevant databases up to January 2019 to identify RCTs or observational studies that compared at least two of three treatment modalities: the use of corticosteroids as a monotherapy (C), corticosteroids as an adjunct to surgery (CS), and surgery alone (S). Outcome measures were good neurological outcome, need for reintervention, mortality, and complications. Effect estimates were pooled and presented as relative risk (RR) with 95% confidence interval (95%CI).

RESULTS

Of 796 initially identified studies, 7 were included in the meta-analysis. Risk of bias was generally high. There were no differences in good neurological outcome between treatment modalities. The need for reintervention varied between 4 and 58% in C, 4-12% in CS, and 7-26% in S. The need for reintervention was lower in CS compared with C (RR 3.34 [95% CI 1.53-7.29]; p < 0.01) and lower in CS compared with S (RR 0.44 [95% CI 0.27-0.72]; p < 0.01). Mortality varied between 0 and 4% in C, 0-13% in CS, and 0-44% in S. Mortality was lower in CS compared with S (RR 0.39 [95% CI 0.25-0.63]; p < 0.01). There were no differences in complications between treatment modalities.

CONCLUSIONS

This meta-analysis suggests that the addition of corticosteroids to surgery might be effective in the treatment of CSDH. However, the results must be interpreted with caution in light of the serious risk of bias of the included studies. This study stresses the need for large randomized trials to investigate the use of corticosteroids in the management of CSDH.

Randomized controlled study on the curative effects of twist-drill craniotomy and burr-hole craniotomy in the treatment of chronic subdural hematoma

The present randomized controlled study investigated the differences in the curative effects of twist-drill craniotomy (TDC) and burr-hole craniotomy (BHC) in the treatment of chronic subdural hematoma (CSDH). A total of 40 patients diagnosed with CSDH via head computed tomography (CT) who required surgical decompression from January 2016 to January 2017 were enrolled in the present study, and were randomly divided into a TDC group (n=20) and a BHC group (n=20). The modified Rankin scale (mRS) scores of patients were recorded prior to the operation, and at 48 h and 3 months after the operation. The differences in the mRS score (V_mRS) among the groups were calculated using the Mann-Whitney U test. The 40 patients enrolled comprised 33 males and 7 females, and there were no significant differences in the general clinical characteristics between the two groups. In the BHC group, 3 patients had a pre-operative mRS score of 5 points, among which 2 cases died at 32 and 45 days after discharge. In the TDC group, 4 patients had a pre-operative mRS score of 5 points, among which 1 case died of epilepsy and pulmonary infection at 1 month after the operation. No difference in the mortality rate was present between the two groups. During the 3-month follow-up, head CT indicated that the intracranial hematoma in a total of 4 patients, including 3 cases in the TDC group and 1 case in the BHC group, completely disappeared. In the BHC group, 3 cases required a repeated incision and drainage after the first operation, while no secondary operation was required in any of the cases of the TDC group. The average length of stay at the hospital (LOS) after TDC was 9.00±2.91 days, which was significantly shorter than that after BHC (14.75±5.95 days). In the total sample of 40 patients, a longer LOS was associated with a higher risk of secondary operation due to recurrence after discharge. The variation value of the mRS score at 3 months after the operation and its ratio vs. the pre-operative score in the TDC group were significantly different from those in the BHC group, suggesting that the improvement of neurological function after TDC was significantly greater than that after BHC. Although 18 patients (90%) in the TDC group were cured, there was no significant difference from the cure rate in the BHC group [15 patients (75%)]. In conclusion, no significant differences were identified in the cure rate and the mortality rate of patients with CSDH after the two types of surgical treatment. However, the mRS score in the TDC group at 3 months after the operation exhibited a significantly greater improvement compared with that in the BHC group, and the overall LOS in the TDC group was significantly shorter than that in BHC group. Therefore, TDC is superior to BHC in the treatment of CSDH (trial registration no. ChiCTR-INR-16008368).

Determining if Cerebrospinal Fluid Prevents Recurrence of Chronic Subdural Hematoma: A Multi-Center Prospective Randomized Clinical Trial

Over the decades, the problem of postoperative recurrence of chronic subdural hematoma (CSDH) has not been resolved. The objective of our study was to investigate whether the recurrence rate of CSDH is decreased when artificial cerebrospinal fluid (ACF) is used as irrigation solution for CSDH surgery. The present study was a multi-center, prospective, randomized, open parallel group comparison test of patients enrolled from 10 hospitals in Japan. Eligible patients with CSDH were randomly assigned to undergo burr hole drainage with either normal saline (NS) or ACF irrigation. The primary end-point was postoperative recurrence of ipsilateral CSDH. A total of 402 patients with newly diagnosed CSDH were enrolled during the study period. After applying inclusion and exclusion criteria, and taking into consideration cases lost to follow-up, our final study cohorts consisted of 177 ACF patients and 165 NS patients, representing 85.7% of the initial cohort. The overall recurrence rate was 11.4%, occurring in 39 of the 342 analyzed patients during 90 days of follow-up. Recurrence rates in the ACF and NS groups were 11.9% (21 of 177) and 10.9% (18 of 165), respectively. No significant difference was evident between groups (p = 0.87). In addition, no significant difference in time to recurrence was seen between groups (p = 0.74). No serious adverse effects related to irrigation fluid were seen in either group. Regarding the irrigation fluid for CSDH surgery, no differences in recurrence rate or time to recurrence were seen between the ACF and NS groups. However, ACF offers sufficient safety as irrigation fluid for CSDH.

Proposal of Treatment Strategies for Bilateral Chronic Subdural Hematoma Based on Laterality of Treated Hematoma

Background:

Chronic subdural hematoma (CSDH) is a disorder that is commonly seen in routine neurosurgery. Although risk factors for recurrence have been studied, the findings are inconsistent. Furthermore, bilateral CSDHs are operated unilaterally or bilaterally depending on symptoms or hematoma volume. Although there are cases in which hematomas on nonoperated side in unilaterally operated bilateral CSDHs requiring for additional operation, little have been studied on the effect of the surgical selection. The purpose of this study is to identify risk factors for recurrence in operated hematomas and additional operation in nonoperated hematomas and improve surgical strategy.

Materials and Methods:

We retrospectively reviewed patients who underwent surgery in our facility for bilateral CSDHs between January 2011 and December 2016. Univariate and multivariate analyses were performed to examine the relationship between recurrence or requirement for additional operation and clinical and radiological variables.

Results:

Recurrence was observed significantly more frequent for operated hematomas when hematoma type was separated type as reported previously. In unilaterally operated bilateral CSDHs, there were 22 hematomas on nonoperated side, and five hematomas required an additional operation after the first hospitalization. Increased volume of hematoma on the nonoperated side was the risk factors for additional operation (P = 0.022). Receiver operating characteristic (ROC) curve revealed that requirement for additional operation significantly increased when hematoma volume enlarged to approximately 44 cm³ or greater 1 day after operation.

Conclusions:

In unilaterally operated bilateral CSDHs, when hematoma volume on nonoperated side increased 1 day after the last operation, additional operation in the early stage is considerable to prevent re-hospitalization and deterioration of activities of daily living.

Predictive Factors for Recurrence after Burr-Hole Craniostomy of Chronic Subdural Hematoma

Objective

Chronic subdural hematoma is a common and relatively benign disease. However, recurrence is common after surgical treatment, and the recurrence rate varies from 5% to 33%. The aim of this study was to investigate the predictive factors for recurrence of chronic subdural hematoma.

Methods

We analyzed data from 248 patients with chronic subdural hematoma who were treated by burr-hole craniostomy with a closed drainage system for hematoma evacuation in this five-year retrospective study.

Results

Thirty-one (12.6%) patients underwent re-operation for recurrence of chronic subdural hematoma. Univariate analysis revealed that anticoagulation (p=0.0279), headache (p=0.0323), and preoperative midline shifting (p=0.0321) showed significant differences with respect to recurrent chronic subdural hematoma. We performed a multivariate logistic regression analysis and found that diabetes mellitus (odds ratio [OR], 2.618; 95% confidence interval [CI], 1.0899-6.2898; p=0.0314), anticoagulation (OR, 6.739; 95% CI, 1.1287-40.2369; p=0.0364), headache (OR, 2.951; 95% CI, 1.1464-7.5964; p=0.0249), and preoperative midline shifting (OR, 1.0838; 95% CI, 1.0040-1.1699; p=0.0391) were independent predictive factors for recurrence of chronic subdural hematoma.

Conclusion

We showed that diabetes mellitus, anticoagulation, headache, and preoperative midline shifting were independent predictors of recurrence of chronic subdural hematoma.

Middle Meningeal Artery Embolization for Chronic Subdural Hematoma

Purpose To evaluate the effect of middle meningeal artery (MMA) embolization on chronic subdural hematoma (CSDH) and compare the treatment outcomes of MMA embolization and conventional treatment. Materials and Methods All consecutive patients 20 years or older with CSDH were assessed for eligibility. CSDHs with a focal location, a thickness of 10 mm or less, no mass effect, or underlying conditions were excluded. Seventy-two prospectively enrolled patients with CSDH underwent MMA embolization (embolization group; as the sole treatment in 27 [37.5%] asymptomatic patients and with additional hematoma removal for symptom relief in 45 [62.5%] symptomatic patients). For comparison, 469 patients who underwent conventional treatment were included as a historical control group (conventional treatment group; close, nonsurgical follow-up in 67 [14.3%] and hematoma removal in 402 [85.7%] patients). Primary outcome was treatment failure defined as a composite of incomplete hematoma resolution (remaining or reaccumulated hematoma with thickness > 10 mm) or surgical rescue (hematoma removal for relief of symptoms that developed with continuous growth of initial or reaccumulated hematoma). Secondary outcomes included surgical rescue as a component of the primary outcome and treatment-related complication for safety measure. Six-month outcomes were compared between the study groups with logistic regression analysis. Results Spontaneous hematoma resolution was achieved in all of 27 asymptomatic patients undergoing embolization without direct hematoma removal. Hematoma reaccumulation occurred in one (2.2%) of 45 symptomatic patients receiving embolization with additional hematoma removal. Treatment failure rate in the embolization group was lower than in the conventional treatment group (one of 72 patients [1.4%] vs 129 of 469 patients [27.5%], respectively; adjusted odds ratio [OR], 0.056; 95% confidence interval [CI]: 0.011, 0.286; P = .001). Surgical rescue was less frequent in the embolization group (one of 72 patients [1.4%] vs 88 of 469 patients [18.8%]; adjusted OR, 0.094; 95% CI: 0.018, 0.488; P = .005). Treatment-related complication rate was not different between the two groups (0 of 72 patients vs 20 of 469 patients [4.3%]; adjusted OR, 0.145; 95% CI: 0.009, 2.469; P = .182). Conclusion MMA embolization has a positive therapeutic effect on CSDH and is more effective than conventional treatment. ^© RSNA, 2017.

Clinical Investigation of Refractory Chronic Subdural Hematoma: A Comparison of Clinical Factors Between Single and Repeated Recurrences

BACKGROUND

Chronic subdural hematoma (CSDH) is sometimes refractory, and this is troublesome for neurosurgeons. Although many studies have reported risk factors or treatments in efforts to prevent recurrence, those have focused on single recurrence, and few cumulative data are available to analyze refractory CSDH.

METHODS

We defined refractory CSDH as ≥2 recurrences, then analyzed and compared clinical factors between patients with single recurrence and those with refractory CSDH in a cohort study, to clarify whether patients with refractory CSDH experience different or more risk factors than patients with single recurrence, and whether burr-hole irrigation with closed-system drainage reduces refractory CSDH.

RESULTS

Seventy-five patients had at least 1 recurrence, with single recurrence in 62 patients and ≥2 recurrences in 13 patients. In comparing clinical characteristics, patients with refractory CSDH were significantly younger (P = 0.04) and showed shorter interval to first recurrence (P < 0.001). Organized CSDH was also significantly associated with refractory CSDH (P = 0.02). Multivariate logistic regression analysis identified first recurrence interval <1 month (odds ratio, 6.66, P < 0.001) and age <71 years (odds ratio, 4.16, P < 0.001) as independent risk factors for refractory CSDH. On the other hand, burr-hole irrigation with closed-system drainage did not reduce refractory CSDH.

CONCLUSIONS

When patients with risk factors for refractory CSDH experience recurrence, alternative surgical procedures may be considered as the second surgery, because burr-hole irrigation with closed-system drainage did not reduce refractory CSDH in our study.