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Scruton TJ. Updates on the diagnosis and management of subdural hematoma. JAAPA 2024; 37:9-15. [PMID: 38980290 DOI: 10.1097/01.jaa.0000000000000055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Abstract
ABSTRACT Intracranial hemorrhage is a potentially life-threatening condition categorized into four main groups by the location of bleeding: epidural, subdural, subarachnoid, and intraparenchymal. Subdural hematoma (SDH) is increasingly common as the population of older adults increases. Clinicians must recognize the typical presentations and order diagnostic imaging studies to make a timely diagnosis and referral to neurosurgery for definitive treatment. Understanding the pathophysiology and risk factors for chronic or expanding SDH informs decision-making in managing anticoagulants. Emerging treatments offer potential alternatives to the traditional evacuation of SDH by craniotomy, which remains the standard of care for most symptomatic patients.
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Affiliation(s)
- Thomas J Scruton
- Thomas J. Scruton has been a PA for more than 20 years, practicing primarily in neurological surgery. The author has disclosed no potential conflicts of interest, financial or otherwise
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2
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Debs LH, Walker SE, Rahimi SY. Newer treatment paradigm improves outcomes in the most common neurosurgical disease of the elderly: a literature review of middle meningeal artery embolization for chronic subdural hematoma. GeroScience 2024:10.1007/s11357-024-01173-5. [PMID: 38691299 DOI: 10.1007/s11357-024-01173-5] [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: 03/22/2024] [Accepted: 04/23/2024] [Indexed: 05/03/2024] Open
Abstract
Chronic subdural hematoma (cSDH) is one of the most prevalent neurosurgical diseases, especially in the elderly. Yet, its incidence is predicted to increase further, paralleling the growth of the geriatric population. While surgical evacuation is technically straightforward, it is associated with significant morbidity and mortality. In fact, 30% of patients are expected to have hematoma recurrence and to need repeat surgical evacuation, and 20% of patients are expected to lose independence and require long-term care. A pathophysiology more complex than originally presumed explains the disappointing results observed for decades. At its core, the formation of microcapillaries and anastomotic channels with the middle meningeal artery (MMA) perpetuates a constant cycle resulting in persistence of hematoma. The rationale behind MMA embolization is simple: to stop cSDH at its source. Over the last few years, this "newer" option has been heavily studied. It has shown tremendous potential in decreasing hematoma recurrence and improving neurological outcomes. Whether combined with surgical evacuation or performed as the only treatment, the scientific evidence to its benefits is unequivocal. Here, we aimed to review cSDH in the elderly and discuss its more recent treatment options with an emphasis on MMA embolization.
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Affiliation(s)
- Luca H Debs
- Neurosurgery Department, Medical College of Georgia, Augusta, GA, USA.
| | - Samantha E Walker
- Neurosurgery Department, Medical College of Georgia, Augusta, GA, USA
| | - Scott Y Rahimi
- Neurosurgery Department, Medical College of Georgia, Augusta, GA, USA
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3
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Wang B, Li K, Guo C, Wang Z, Zhu W, Lu C. Evaluation of Effectiveness of Atorvastatin in Treating Chronic Subdural Hematoma not Requiring Surgery: A Meta-Analysis of Randomized Controlled Trials. Ann Indian Acad Neurol 2024; 27:19-26. [PMID: 38495243 PMCID: PMC10941892 DOI: 10.4103/aian.aian_818_23] [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: 09/13/2023] [Revised: 12/14/2023] [Accepted: 12/17/2023] [Indexed: 03/19/2024] Open
Abstract
Chronic subdural hematoma (CSDH) is a chronic space-occupying lesion formed by blood accumulation between the arachnoid membrane and the dura mater. Atorvastatin is of increasing clinical interest for CSDH. We performed a meta-analysis of published randomized controlled trials (RCTs) and used objective data as the primary outcomes to provide an evidence-based analysis of the efficacy of atorvastatin for CSDH treatment. Databases of MEDLINE (via PubMed), EMBASE, the Cochrane Library, Scopus, Web of Science, ScienceDirect, Chinese National Knowledge Infrastructure (CNKI), Cqvip database (CQVIP), and Wanfang database were systematically searched for RCTs reporting the use of atorvastatin for CSDH treatment. Odds ratio (OR), standard mean difference (SMD), and 95% confidence intervals (CIs) were used as summary statistics. I-square (I2) test was performed to assess the impact of study heterogeneity on the results of the meta-analysis. Nine relevant RCTs with 611 patients were identified for inclusion in this meta-analysis. Compared to controls, atorvastatin treatment had a significantly higher effectiveness (OR: 7.41, 95% CI: 3.32-16.52, P < 0.00001, I2 = 0%), lower hematoma volume (SMD: -0.46. 95% CI: -0.71 to -0.20, P = 0.0005, I2 = 0%), higher activities of daily living-Barthel Index (ADL-BI) (SMD: 2.07, 95% CI: 1.06-3.09, P < 0.0001, I2 = 92%), and smaller Chinese stroke scale (CSS) (SMD: -1.10, 95% CI: -1.72 to -0.48, P = 0.0005, I2 = 57%). In view of these findings, we conclude that the outcomes of experimental group are superior to the control group with respect to effectiveness, hematoma volume, ADL-BI, and CSS based on nine RCTs with 611 patients. Atorvastatin is beneficial to CSDH patients without surgery.
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Affiliation(s)
- Bo Wang
- Qingdao University Medical College Affiliated Yantai Yuhuangding Hospital, Yantai, Shandong, China
| | - Kangqi Li
- Qingdao University Medical College Affiliated Yantai Yuhuangding Hospital, Yantai, Shandong, China
| | - Chenyu Guo
- Qingdao University Medical College Affiliated Yantai Yuhuangding Hospital, Yantai, Shandong, China
| | - Zhe Wang
- Qingdao University Medical College Affiliated Yantai Yuhuangding Hospital, Yantai, Shandong, China
| | - Weiwei Zhu
- Qingdao University Medical College Affiliated Yantai Yuhuangding Hospital, Yantai, Shandong, China
| | - Congxiao Lu
- Qingdao University Medical College Affiliated Yantai Yuhuangding Hospital, Yantai, Shandong, China
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Zhang J, Yu L, Wang X, Yu Q, Zhu B, Zhang H, Liu Y, Li H, Zhang A, Wang K, He Y, Wu Q, Fang Y, Sun J, Chen S. The Drainage Dysfunction of Meningeal Lymphatic Vessels Is Correlated with the Recurrence of Chronic Subdural Hematoma: a Prospective Study. Transl Stroke Res 2023:10.1007/s12975-023-01227-4. [PMID: 38133745 DOI: 10.1007/s12975-023-01227-4] [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: 09/27/2023] [Revised: 11/15/2023] [Accepted: 12/08/2023] [Indexed: 12/23/2023]
Abstract
Meningeal lymphatic vessels (mLVs) were recently discovered to be involved in the waste drainage process in the brain, which has also been associated with a variety of neurological diseases. This research paper hypothesizes that the drainage function of mLVs may be affected after chronic subdural hematoma (CSDH) and the alterations of mLVs' drainage may predict CSDH recurrence. In this prospective observational study, unenhanced 3D T2-fluid-attenuated inversion recovery (3D T2-FLAIR) MRI data were collected from CSDH patients and healthy participants for analysis. Patients with CSDH who underwent surgery received MRI scans before and after surgery, whereas healthy controls and patients with CSDH who received pharmaceutical treatment received only one MRI scan at enrollment. The signal unit ratio (SUR) of mLVs were then measured according to the MRI data and calculated to define mLVs' drainage function. Finally, the relationship between mLVs' drainage function and CSDH recurrence was analyzed accordingly. Thirty-four participants were enrolled in this study, including 27 CSDH patients and 7 controls. The SUR of mLVs in all CSDH patients changed significantly before and after surgery. Moreover, the drainage function of the mLVs ipsilateral to hematoma (mLVs-IH) in CSDH patients was significantly lower than that in the controls (p < 0.05). Last, a higher improvement rate of the drainage function of the mLVs-IH is correlated to a lower risk of recurrence (p < 0.05). This study revealed the mLVs' drainage dysfunction after CSDH through non-invasive MRI. Furthermore, the drainage function of mLVs is an independent predictive factor of CSDH recurrence.
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Affiliation(s)
- Jiahao Zhang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Lei Yu
- Department of Radiology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xiaoyu Wang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Qian Yu
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Bingrui Zhu
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Haocheng Zhang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Yibo Liu
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Huaming Li
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Anke Zhang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Kaikai Wang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Yezhao He
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Qun Wu
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Yuanjian Fang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China.
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China.
| | - Jianzhong Sun
- Department of Radiology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.
| | - Sheng Chen
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China.
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China.
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5
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Aziz N, O'Halloran PJ, McKenna GS. Subdural haematoma in the elderly: management and outcomes of a UK Major Trauma Centre. Br J Neurosurg 2023; 37:1604-1612. [PMID: 36218868 DOI: 10.1080/02688697.2022.2122402] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 09/04/2022] [Indexed: 11/02/2022]
Abstract
BACKGROUND An estimated 40% of all traumatic brain injury (TBI) occurs in ≥70-year-olds with a high prevalence of traumatic subdural haematoma (tSDH). It is anticipated that an expanding elderly population will lead to a proportional increase in the incidence of patients with tSDH presenting to UK trauma centres, but the long-term clinical outcomes and factors influencing functional outcomes in this patient group remain poorly understood. AIM To examine the management and clinical outcomes for elderly (≥70 years) patients diagnosed with tSDH. METHODS Patient data for this single-centre, retrospective cohort study were analysed from a Major Trauma Centre (MTC) electronic patient records between January 2013 and December 2019. RESULTS Two hundred and eighty patients were included, 43% aged 70-79, 42% aged 80-89 and 15% >90. In total, 37% underwent a surgical intervention. The 6-month survival in the severe, moderate, and mild TBI groups was 14%, 43%, and 67%, respectively. The 6-month survival in the surgical group was 58%, vs. 60% in the conservatively managed group. Surgical intervention did not significantly impact Extended Glasgow Coma Score (GOS-E) at 6 months, regardless of injury severity. Advanced age (p = 0.04), mixed intracranial injuries (p < 0.0001), craniotomies (p = 0.03), and poor premorbid performance status (p = 0.02) were associated with worse survival and functional outcomes. CONCLUSIONS Our study demonstrated that increasing age, increasing severity of TBI and poorer premorbid performance status were associated with significantly poorer 6-month survival and functional outcomes in elderly patients with tSDH. Burr hole evacuation was associated with better functional outcomes compared to craniotomy, but overall, there was no significant difference in the outcomes of the surgical and non-surgical groups. We identified strong risk factors for death and poor functional outcomes at 6-months which are important to consider when counselling patients and families about the long-term prognosis of elderly patients with tSDH and can help guide clinical decision-making.
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Affiliation(s)
- Natasha Aziz
- School of Medicine, Queen Mary University of London, London, UK
| | - Philip J O'Halloran
- Department of Neurosurgery, Royal London Hospital, London, UK
- Department of Physiology & Medical Physics, Royal College of Surgeons in Ireland, London, UK
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Chen H, Salem MM, Colasurdo M, Sioutas GS, Khalife J, Kuybu O, Carroll KT, Hoang AN, Baig AA, Salih M, Khorasanizadeh M, Baker C, Mendez Ruiz A, Cortez GM, Abecassis Z, Ruiz Rodríguez JF, Davies JM, Narayanan S, Cawley CM, Riina H, Moore J, Spiotta AM, Khalessi A, Howard BM, Hanel RA, Tanweer O, Tonetti D, Siddiqui AH, Lang M, Levy EI, Jovin TG, Grandhi R, Srinivasan VM, Levitt MR, Ogilvy CS, Jankowitz B, Thomas AJ, Gross BA, Burkhardt JK, Kan P. Standalone middle meningeal artery embolization versus middle meningeal artery embolization with concurrent surgical evacuation for chronic subdural hematomas: a multicenter propensity score matched analysis of clinical and radiographic outcomes. J Neurointerv Surg 2023:jnis-2023-020907. [PMID: 37932033 DOI: 10.1136/jnis-2023-020907] [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: 08/12/2023] [Accepted: 10/19/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND Middle meningeal artery embolization (MMAE) has emerged as a promising therapy for chronic subdural hematomas (cSDHs). The efficacy of standalone MMAE compared with MMAE with concurrent surgery is largely unknown. METHODS cSDH patients who underwent successful MMAE from 14 high volume centers with at least 30 days of follow-up were included. Clinical and radiographic variables were recorded and used to perform propensity score matching (PSM) of patients treated with standalone MMAE or MMAE with concurrent surgery. Multivariable logistic regression models were used for additional covariate adjustments. The primary outcome was recurrence requiring surgical rescue, and the secondary outcome was radiographic failure defined as <50% reduction of cSDH thickness. RESULTS 722 MMAE procedures in 588 cSDH patients were identified. After PSM, 230 MMAE procedures remained (115 in each group). Median age was 73 years, 22.6% of patients were receiving anticoagulation medication, and 47.9% had no preoperative functional disability. Median midline shift was 4 mm and cSDH thickness was 16 mm, representing modestly sized cSDHs. Standalone MMAE and MMAE with surgery resulted in similar rates of surgical rescue (7.8% vs 13.0%, respectively, P=0.28; adjusted OR (aOR 0.73 (95% CI 0.20 to 2.40), P=0.60) and radiographic failure (15.5% vs 13.7%, respectively, P=0.84; aOR 1.08 (95% CI 0.37 to 2.19), P=0.88) with a median follow-up duration of 105 days. These results were similar across subgroup analyses and follow-up durations. CONCLUSIONS Standalone MMAE led to similar and durable clinical and radiographic outcomes as MMAE combined with surgery in select patients with moderately sized cSDHs and mild clinical disease.
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Affiliation(s)
- Huanwen Chen
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
- Neurology, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Mohamed M Salem
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Marco Colasurdo
- Interventional Radiology, Oregon Health and Science University, Portland, Oregon, USA
| | - Georgios S Sioutas
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jane Khalife
- Department of Neurosurgery, Cooper Medical School of Rowan University, Camden, New Jersey, USA
| | - Okkes Kuybu
- Department of Neurology and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Kansas, USA
| | - Kate T Carroll
- Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Alex Nguyen Hoang
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Ammad A Baig
- Neurosurgery, Buffalo State, The State University of New York, Buffalo, New York, USA
| | - Mira Salih
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | | - Cordell Baker
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Aldo Mendez Ruiz
- Department of Neurology and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Kansas, USA
| | | | - Zack Abecassis
- Department of Neurosurgery, University of Washington, Seattle, Washington, USA
| | | | - Jason M Davies
- Neurosurgery and Biomedical Engineering, Toshiba Stroke and Vascular Research Institute, University at Buffalo, State University of New York, Buffalo, New York, USA
| | - Sandra Narayanan
- Department of Neurology, Neurosurgery, UPMC, Pittsburgh, Pennsylvania, USA
| | | | | | - Justin Moore
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Alejandro M Spiotta
- Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Alexander Khalessi
- Department of Neurological Surgery, University of California San Diego, La Jolla, California, USA
| | - Brian M Howard
- Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
- Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ricardo A Hanel
- Lyerly Neurosurgery, Baptist Medical Center Downtown, Jacksonville, Florida, USA
| | - Omar Tanweer
- Department of Neurosurgery, NYU Langone Health, New York, New York, USA
| | - Daniel Tonetti
- Department of Neurosurgery, Cooper University Health Care, Camden, New Jersey, USA
| | - Adnan H Siddiqui
- Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
- Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
| | - Michael Lang
- Department of Neurosurgery, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
| | - Elad I Levy
- Department of Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Tudor G Jovin
- Neurology, Cooper University Hospital, Camden, New Jersey, USA
| | - Ramesh Grandhi
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | | | - Michael R Levitt
- Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | | | - Brian Jankowitz
- Neurosurgery, University of Pennsylvania, Camden, Pennsylvania, USA
| | - Ajith J Thomas
- Department of Neurosurgery, Cooper University Health Care, Camden, New Jersey, USA
| | - Bradley A Gross
- Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jan Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Peter Kan
- Neurosurgery, University of Texas Medical Branch at Galveston, Galveston, Texas, USA
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Ku JC, Dmytriw AA, Essibayi MA, Banihashemi MA, Vranic JE, Ghozy S, Altschul D, Regenhardt RW, Stapleton CJ, Yang VXD, Patel AB. Embolic Agent Choice in Middle Meningeal Artery Embolization as Primary or Adjunct Treatment for Chronic Subdural Hematoma: A Systematic Review and Meta-analysis. AJNR Am J Neuroradiol 2023; 44:297-302. [PMID: 36797028 PMCID: PMC10187811 DOI: 10.3174/ajnr.a7796] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 01/24/2023] [Indexed: 02/18/2023]
Abstract
BACKGROUND Middle meningeal artery embolization is an emerging treatment option for chronic subdural hematomas. PURPOSE Our aim was to assess outcomes following middle meningeal artery embolization by different techniques, including in comparison with traditional surgical methods. DATA SOURCES We searched the literature databases from inception to March 2022. DATA SELECTION We selected studies reporting outcomes after middle meningeal artery embolization as a primary or adjunctive treatment for chronic subdural hematoma. DATA ANALYSIS We analyzed the risk of recurrence of chronic subdural hematoma, reoperation for recurrence or residual hematoma, complications, and radiologic and clinical outcomes using random effects modeling. Additional analyses were performed on the basis of whether middle meningeal artery embolization was used as the primary or adjunct treatment and by embolic agent type. DATA SYNTHESIS Twenty-two studies were included with 382 patients with middle meningeal artery embolization and 1373 surgical patients. The rate of subdural hematoma recurrence was 4.1%. Fifty (4.2%) patients underwent a reoperation for a recurrent or residual subdural hematoma. Thirty-six (2.6%) experienced postoperative complications. The rates of good radiologic and clinical outcomes were 83.1% and 73.3%, respectively. Middle meningeal artery embolization was significantly associated with decreased odds of subdural hematoma reoperation (OR = 0.48; 95% CI, 23.4-99.1; P = .047) compared with surgery. The lowest rates of subdural hematoma radiologic recurrence, reoperation, and complications were observed among patients receiving embolization with Onyx, whereas good overall clinical outcome occurred most commonly with combined polyvinyl alcohol and coils. LIMITATIONS A limitation was the retrospective design of studies included. CONCLUSIONS Middle meningeal artery embolization is safe and effective, either as a primary or adjunctive treatment. Treatment using Onyx seems to yield lower rates of recurrence, rescue operation, and complications whereas particles and coils produce good overall clinical outcomes.
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Affiliation(s)
- J C Ku
- From the Division of Neurosurgery (J.C.K.)
| | - A A Dmytriw
- Neuroendovascular Program (A.A.D., J.E.V., R.W.R., C.J.S., A.B.P.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- Neurointerventional Program (A.A.D., V.X.D.Y.), Department of Clinical Neurological Sciences & Medical Imaging, Schulich School of Medicine, Western University, London, Ontario, Canada
| | - M A Essibayi
- Departments of Radiology (M.A.E., S.G.), Mayo Clinic, Rochester, Minnesota
- Department of Neurosurgery (M.A.E., D.A.), Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York
| | - M A Banihashemi
- Department of Surgery and Institute of Medical Science (M.A.B.), University of Toronto, Toronto, Ontario, Canada
| | - J E Vranic
- Neuroendovascular Program (A.A.D., J.E.V., R.W.R., C.J.S., A.B.P.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - S Ghozy
- Departments of Radiology (M.A.E., S.G.), Mayo Clinic, Rochester, Minnesota
- Nuffield Department of Primary Care Health Sciences and Department for Continuing Education (EBHC program) (S.G.), Oxford University, Oxford, UK
| | - D Altschul
- Department of Neurosurgery (M.A.E., D.A.), Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York
| | - R W Regenhardt
- Neuroendovascular Program (A.A.D., J.E.V., R.W.R., C.J.S., A.B.P.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - C J Stapleton
- Neuroendovascular Program (A.A.D., J.E.V., R.W.R., C.J.S., A.B.P.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - V X D Yang
- Neurointerventional Program (A.A.D., V.X.D.Y.), Department of Clinical Neurological Sciences & Medical Imaging, Schulich School of Medicine, Western University, London, Ontario, Canada
| | - A B Patel
- Neuroendovascular Program (A.A.D., J.E.V., R.W.R., C.J.S., A.B.P.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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8
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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.
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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
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9
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Saway BF, Roth W, Salvador CD, Essibayi MA, Porto GBF, Dowlati E, Felbaum DR, Rock M, Withington C, Desai SK, Hassan AE, Tekle WG, Spiotta A. Subdural evacuation port system and middle meningeal artery embolization for chronic subdural hematoma: a multicenter experience. J Neurosurg 2022:1-8. [PMID: 36681990 DOI: 10.3171/2022.10.jns221476] [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: 06/22/2022] [Accepted: 10/07/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Middle meningeal artery (MMA) embolization and the Subdural Evacuation Port System (SEPS) are minimally invasive treatment paradigms for chronic subdural hematoma (cSDH). Although SEPS offers acute decompression of local mass effect from a cSDH, MMA embolization has been shown to reduce the rate of cSDH recurrence. In combination, these procedures present a potentially safer strategy to a challenging pathology. The authors present a multi-institutional retrospective case series that assessed the safety, efficacy, and complications of SEPS and MMA embolization for cSDH. METHODS A retrospective review was performed of patients who underwent SEPS placement and MMA embolization for cSDH between 2018 and 2021 at three institutions. RESULTS One hundred patients with 136 cSDHs and a median age of 73 years underwent both SEPS placement and MMA embolization. Initial Glasgow Coma Scale scores were between 14 and 15 in 81% of patients and between 9 and 13 in 14%. The median initial midline shift (MLS) was 7 mm, with subdural hematoma (SDH) in the left hemisphere (lh) in 30% of patients, right hemisphere (rh) in 34%, and bilateral hemispheres in 36%. Follow-up was available for 86 patients: 93.4% demonstrated decreased MLS, and all patients with lhSDH and rhSDH demonstrated progressive decrease in SDH size. The overall complication rate was 4%, including 1 case of facial palsy and 3 cases of iatrogenic acute SDH. Two subjects (2%) required craniotomy for hematoma evacuation. The rate of good functional outcomes, with modified Rankin Scale (mRS) score < 2, was 89% on final follow-up and the overall mortality rate was 2%. A good mRS score on admission was associated with increased odds of functional improvement at follow-up (p < 0.001). CONCLUSIONS SEPS placement with MMA embolization for cSDH can be done safely and effectively reduces cSDH size with minimal perioperative morbidity.
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Affiliation(s)
- Brian F Saway
- 1Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | - Warren Roth
- 2College of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Craig D Salvador
- 2College of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Muhammed Amir Essibayi
- 1Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | - Guilherme B F Porto
- 1Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | - Ehsan Dowlati
- 3Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC
| | - Daniel R Felbaum
- 3Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC
| | - Mitchell Rock
- 3Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC
| | - Charles Withington
- 3Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC
| | - Sohum K Desai
- 4Department of Surgery, University of Texas Rio Grande Valley School of Medicine, Harlingen, Texas; and
| | - Ameer E Hassan
- 4Department of Surgery, University of Texas Rio Grande Valley School of Medicine, Harlingen, Texas; and
| | - Wondwossen G Tekle
- 5Department of Neuroscience, Valley Baptist Medical Center, Harlingen, Texas
| | - Alejandro Spiotta
- 1Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
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10
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Yue JK, Haddad AF, Wang AS, Caldwell DJ, Umbach G, Digiorgio AM, Tarapore PE, Huang MC, Manley GT. Evacuation of a multi-loculated acute-on-chronic subdural hematoma using tandem bedside subdural evacuation port systems. Trauma Case Rep 2022; 40:100668. [PMID: 35794957 PMCID: PMC9251328 DOI: 10.1016/j.tcr.2022.100668] [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] [Accepted: 06/26/2022] [Indexed: 11/30/2022] Open
Abstract
Background Purpose Findings Conclusions
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Affiliation(s)
- John K. Yue
- Corresponding author at: Department of Neurological Surgery, University of California, San Francisco, 1001 Potrero Avenue, Bldg 1, Rm 101, San Francisco, CA 94143, United States of America.
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11
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Di Cristofori A, Remida P, Patassini M, Piergallini L, Buonanno R, Bruno R, Carrabba G, Pavesi G, Iaccarino C, Giussani CG. Middle meningeal artery embolization for chronic subdural hematomas. A systematic review of the literature focused on indications, technical aspects, and future possible perspectives. Surg Neurol Int 2022; 13:94. [PMID: 35399896 PMCID: PMC8986643 DOI: 10.25259/sni_911_2021] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 02/14/2022] [Indexed: 12/20/2022] Open
Abstract
Background: Chronic subdural hematoma (CSDH) is one of the most common neurosurgical diseases that affect elderly and fragile patients and as a consequence, management can be challenging. Surgery represents the standard treatment; however, alternative options are under investigation. Middle meningeal artery (MMA) embolization is considered a minimally invasive treatment although with poor evidence. In this review, we tried to summarize the findings about MMA embolization as a treatment for a CSDH to provide a useful guidance for clinical practice and for future speculative aspects. Methods: Literature review on PubMed until March 2021 was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement. We conducted a research on PubMed with a various combinations of the keywords “CSDH” and “middle meningeal artery” and “embolization,” “refractory subdural hematoma,” and then we reviewed the references of the relevant studies as additional source of eligible articles. Results: Among the 35 studies eligible for this review, 22 were case series, 11 were case reports, one was a technical note, and 1 was a randomized trial. A total of 746 patients were found in the literature. Failure rate of MMA embolization was between 3.9 and 8.9% of the cases according the indication to treat CSDH (upfront vs. after surgery). Conclusion: The global impression deriving from the data available and the literature is that MMA embolization is a safe procedure with very low complications and with a low failure rate, both when associated with surgery or in case of a standalone treatment.
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Affiliation(s)
- Andrea Di Cristofori
- Unit of Neurosurgery, Azienda Socio SanitariaTerritoriale - Monza, Ospedale San Gerardo,
| | - Paolo Remida
- Unit of Neuroradiology, Azienda Socio Sanitaria Territoriale - Monza, Ospedale San Gerardo, Monza,
| | - Mirko Patassini
- Unit of Neuroradiology, Azienda Socio Sanitaria Territoriale - Monza, Ospedale San Gerardo, Monza,
| | - Lorenzo Piergallini
- Unit of Neuroradiology, Azienda Socio Sanitaria Territoriale - Monza, Ospedale San Gerardo, Monza,
| | - Raffaella Buonanno
- Unit of Neurosurgery, Azienda Socio SanitariaTerritoriale - Monza, Ospedale San Gerardo,
- Unit of Neurosurgery, School of Medicine and Surgery, Department of Medicine and Surgery, Università degli Studi Milano Bicocca, Milan,
| | - Raffaele Bruno
- Unit of Neurosurgery, Azienda Socio SanitariaTerritoriale - Monza, Ospedale San Gerardo,
- Unit of Neurosurgery, School of Medicine and Surgery, Department of Medicine and Surgery, Università degli Studi Milano Bicocca, Milan,
| | - Giorgio Carrabba
- Unit of Neurosurgery, Azienda Socio SanitariaTerritoriale - Monza, Ospedale San Gerardo,
- Unit of Neurosurgery, School of Medicine and Surgery, Department of Medicine and Surgery, Università degli Studi Milano Bicocca, Milan,
| | - Giacomo Pavesi
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia,
- Neurosurgery Division, University Hospital of Modena, Modena, Italy
| | - Corrado Iaccarino
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia,
- Neurosurgery Division, University Hospital of Modena, Modena, Italy
| | - Carlo Giorgio Giussani
- Unit of Neurosurgery, Azienda Socio SanitariaTerritoriale - Monza, Ospedale San Gerardo,
- Unit of Neurosurgery, School of Medicine and Surgery, Department of Medicine and Surgery, Università degli Studi Milano Bicocca, Milan,
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12
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Zhuang Z, Chen Z, Chen H, Chen B, Zhou J, Liu A, Luo J. Using Local Anesthesia for Burr Hole Surgery of Chronic Subdural Hematoma Reduces Postoperative Complications, Length of Stay, and Hospitalization Cost: A Retrospective Cohort Study From a Single Center. Front Surg 2022; 9:783885. [PMID: 35433811 PMCID: PMC9010536 DOI: 10.3389/fsurg.2022.783885] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 03/11/2022] [Indexed: 02/05/2023] Open
Abstract
PURPOSE The purpose of the current study was to compare the effects of local anesthesia (LA) and general anesthesia (GA) on the surgical process and postoperative recovery of patients with unilateral chronic subdural hematoma (CSDH). PATIENTS AND METHODS A retrospective cohort study was conducted on patients with unilateral CSDH who underwent burr hole surgery between the years 2013 and 2018. Patients who received local anesthesia were allocated to the LA group, and the patients who received general anesthesia were allocated to the GA group. The clinical data, postoperative complication, length of stay, and hospitalization cost of these two groups were compared and analyzed. RESULTS Data from 105 patients was collected for this study. Fifty one patients were assigned to the LA group and 54 to GA group. The duration of anesthesia and operation of the LA group was 37.71 (10.55) min; while for the GA group the duration was 56.04 (8.37) min (p < 0.001). The time from operation to discharge in GA group was greatly longer than that in LA group [(8.51 (1.49) days vs. 10.46 (2.34) days, respectively; p < 0.001]. Hospitalization cost for LA group was 2,721.54 (504.66) USD, which was significantly lesser than that for GA patients [3,314.82 (493.52) USD; p < 0.001]. The total number of complications in LA patients was less than that in GA patients [6 vs. 29 cases, respectively; p < 0.001]. The number of patients with residual hematoma in the LA group was <that in the GA group (p = 0.014). CONCLUSION As compared to GA, LA might be a simpler, safer, and more effective method for burr hole surgery of CSDH to promote patients' recovery. However, further research is still required to confirm this conclusion.
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Affiliation(s)
- Zerui Zhuang
- Department of Neurosurgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
- Department of Neurosurgery, Shantou Central Hospital, Shantou, China
- Department of Neurosurgery, Second Affiliated Hospital, Shantou University Medical College, Shantou, China
| | - Zelin Chen
- Department of Neurosurgery, Second Affiliated Hospital, Shantou University Medical College, Shantou, China
| | - Hui Chen
- Department of Neurosurgery, Second Affiliated Hospital, Shantou University Medical College, Shantou, China
| | - Bin Chen
- Department of Neurosurgery, Second Affiliated Hospital, Shantou University Medical College, Shantou, China
| | - Jianzhi Zhou
- Department of Neurosurgery, Second Affiliated Hospital, Shantou University Medical College, Shantou, China
| | - Anmin Liu
- Department of Neurosurgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Jianming Luo
- Department of Neurosurgery, Second Affiliated Hospital, Shantou University Medical College, Shantou, China
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13
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Stanishevskiy AV, Babichev KN, Vinogradov EV, Gizatullin SK, Svistov DV, Kandyba DV, Savello AV. [Middle meningeal artery embolization for chronic subdural haematoma. Case series and literature review]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2021; 85:71-79. [PMID: 34714006 DOI: 10.17116/neiro20218505171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Middle meningeal artery embolization as primary method for treatment of chronic subdural hematomas became more popular in past decade. There are few large case series (>150 patients) and literature reviews characterizing advantages and drawbacks of endovascular treatment and technical features of surgeries. In this manuscript, the authors report 11 patients with chronic subdural hematoma scheduled for middle meningeal artery embolization and review the literature data on this issue.
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Affiliation(s)
| | - K N Babichev
- Kirov Military Medical Academy, St. Petersburg, Russia.,Dzhanelidze Saint Petersburg Research Institute for Emergency Care, St. Petersburg, Russia
| | - E V Vinogradov
- Burdenko Main Military Clinical Hospital, Moscow, Russia
| | | | - D V Svistov
- Kirov Military Medical Academy, St. Petersburg, Russia
| | - D V Kandyba
- Kirov Military Medical Academy, St. Petersburg, Russia.,Dzhanelidze Saint Petersburg Research Institute for Emergency Care, St. Petersburg, Russia
| | - A V Savello
- Kirov Military Medical Academy, St. Petersburg, Russia
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14
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Endovascular Treatment of Chronic Subdural Hematomas through Embolization: A Pilot Study with a Non-Adhesive Liquid Embolic Agent of Minimal Viscosity (Squid). J Clin Med 2021; 10:jcm10194436. [PMID: 34640453 PMCID: PMC8509410 DOI: 10.3390/jcm10194436] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 09/17/2021] [Accepted: 09/18/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Endovascular embolization using non-adhesive agents (e.g., ethylene vinyl alcohol copolymer with suspended micronized tantalum dissolved in dimethyl sulfoxide; Squid, Balt Extrusion) is an established treatment of brain arteriovenous malformations, dural arteriovenous fistulas, and hypervascular neoplasms. Middle meningeal artery (MMA) embolization is a relatively new concept for treating chronic subdural hematomas (CSDH). This study aimed to evaluate the safety and effectiveness of the use of Squid in the endovascular treatment of CSDH. METHODS Embolization was offered to patients with CSDH with minimal or moderate neurological deficits and patients who had previously undergone open surgery to evacuate their CSDH without a significant effect. Distal catheterization of the MMA was followed by embolization of the hematoma capsule with Squid 12 or Squid 18. Safety endpoints were ischemic or hemorrhagic stroke and any other adverse event of the endovascular procedure. Efficacy endpoints were the feasibility of the intended procedure and a ≥ 50% reduction of the maximum depth of the CSDH confirmed by follow-up computed tomography (CT) after >3 months. RESULTS Between November 2019 and July 2021, 10 patients (3 female and 7 male, age range 42-89 years) were enrolled. Five patients had bilateral hematomas, and five patients had previously been operated on with no significant effect and recurrent hematoma formation. The attempted embolization was technically possible in all patients. No technical or clinical complication was encountered. During a post-procedural follow-up (median 90 days), 10 patients improved clinically. A complete resolution of the CSDH was observed in 10 patients. The clinical condition of all enrolled patients during the so-far last contact was rated mRS 0 or 1. CONCLUSION A distal catheterization of the MMA for the endovascular embolization of CSDH with Squid allowed for the devascularization of the MMA and the dependent vessels of the hematoma capsule. This procedure resulted in a partial or complete resolution of the CSDH. Procedural complications were not encountered.
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15
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A matter of frailty: the modified Subdural Hematoma in the Elderly (mSHE) score. Neurosurg Rev 2021; 45:701-708. [PMID: 34231088 PMCID: PMC8827338 DOI: 10.1007/s10143-021-01586-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 05/05/2021] [Accepted: 06/14/2021] [Indexed: 10/27/2022]
Abstract
The Subdural Hematoma in the Elderly (SHE) score was developed as a model to predict 30-day mortality from acute, chronic, and mixed subdural hematoma in the elderly population after minor or no trauma. Emerging evidence suggests frailty to be predictive of mortality and morbidity in the elderly. In this study, we aim to externally validate the SHE for chronic subdural hematoma (CSDH) alone, and we hypothesize that the incorporation of frailty into the SHE may increase its predictive power. A retrospective cohort of elderly patients with CSDH after minor or no trauma being treated at our institution was evaluated with the SHE. Thirty-day mortality and outcome were documented. Patients were assessed with the Clinical Frailty Scale (CFS), which was incorporated into a modified SHE (mSHE). Both the SHE and the mSHE were then assessed in their predictive powers through receiver operating characteristic statistics. We included 168 patients. Most (n = 124, 74%) had a favorable outcome at 30 days. Mortality was low at n = 7, 4%. The SHE failed to predict mortality (AUC = .564, p = .565). Contrarily, the mSHE performed well in both mortality (AUC = .749, p = .026) and outcome (AUC = .862, p < .001). A threshold of mSHE = 3 is predictive of mortality with a sensitivity of 50% and a specificity of 75% and of poor outcome with a sensitivity of 88% and a specificity of 64%. Frailty should be routinely evaluated in elderly individuals, as it can predict outcome and mortality, providing the possibility for medical, surgical, nutritional, cognitive, and physical exercise interventions.
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16
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Wang X, Song J, He Q, You C. Pharmacological Treatment in the Management of Chronic Subdural Hematoma. Front Aging Neurosci 2021; 13:684501. [PMID: 34276343 PMCID: PMC8280518 DOI: 10.3389/fnagi.2021.684501] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 05/18/2021] [Indexed: 02/05/2023] Open
Abstract
Background: Several pharmacological treatments have been used to treat patients with chronic subdural hematoma (CSDH), although little is known about the comparative effectiveness of different classes of medication. We performed a Bayesian network meta-analysis to compare and rank the efficacy and safety of five drug regimens to determine the best treatment for this group of patients. Methods: We systematically searched PubMed, Medline, clinicaltrials.gov, the Cochrane database, and Embase to identify relevant randomized clinical trials (RCTs) comparing drug treatments in adult patients with CSDH. A network meta-analysis was conducted using a Bayesian framework. Random- and fixed-effects models were used to pool the network results, and the preferred model was selected by comparing the deviance information criteria (DIC). Efficacy outcomes included recurrence requiring surgery, changes in hematoma volume, and a good recovery. The safety outcomes were treatment-related adverse events and all-cause mortality. Results: In this Bayesian network meta-analysis, available data were obtained from 12 eligible trials, including 2,098 patients and 5 techniques. Compared to placebo, atorvastatin (RR: 0.45, 95% CrI: 0.24-0.81) and dexamethasone (RR: 0.38, 95% CrI: 0.22-0.63) were similarly effective in reducing recurrence requiring surgery by 55% and 62%, respectively. Dexamethasone (RR: 0.46, 95% CrI: 0.23-0.91) was more effective in reducing recurrence requiring surgery than goreisan. Additionally, atorvastatin reduced the hematoma volume to a greater extent than placebo (MD: -7.44, 95% CrI: -9.49 to -5.43) or goreisan (MD: -14.09, 95% CrI: -23.35 to -4.82). Moreover, tranexamic acid (MD: -12.07, 95% CrI: -21.68 to -2.29) reduced the hematoma volume to a greater extent than goreisan. No significant differences were detected between drugs and placebo with regard to a good recovery. In terms of safety, dexamethasone (RR: 1.96, 95% CrI: 1.20-3.28) increased the risk of mortality compared to placebo. Conclusion: These findings suggest that dexamethasone is the best treatment to reduce recurrence and atorvastatin is the best treatment to reduce hematoma volume in patients with CSDH. However, clinicians should pay close attention to the elevated risk of all-cause mortality and potential adverse events caused by dexamethasone. Future well-designed RCTs with more participants are needed to verify these findings. Clinical Trial Registration: http://osf.io/u9hqp.
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Affiliation(s)
- Xing Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jinlei Song
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu, China
| | - Qiang He
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
- Department of Neurosurgery, West China Brain Research Centre, Sichuan University, Chengdu, China
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17
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Carpenter A, Rock M, Dowlati E, Miller C, Mai JC, Liu AH, Armonda RA, Felbaum DR. Middle meningeal artery embolization with subdural evacuating port system for primary management of chronic subdural hematomas. Neurosurg Rev 2021; 45:439-449. [PMID: 33893872 DOI: 10.1007/s10143-021-01553-x] [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: 12/28/2020] [Revised: 03/14/2021] [Accepted: 04/19/2021] [Indexed: 11/30/2022]
Abstract
Optimal treatment for chronic subdural hematomas remains controversial and perioperative risks and comorbidities may affect management strategies. Minimally invasive procedures are emerging as alternatives to the standard operative treatments. We evaluate our experience with middle meningeal artery (MMA) embolization combined with Subdural Evacuating Port System (SEPS) placement as a first-line treatment for patients with cSDH. A single institution retrospective review was performed of all patients undergoing intervention. Patients were stratified by treatment with MMA embolization and SEPS placement, MMA embolization and surgery, SEPS placement only, and surgery only for cSDH from 2017 to 2020, and cohorts were compared against each other. Patients treated with MMA/SEPS were more likely to be older, be on anticoagulation, have significant comorbidities, have shorter length of stay, and less likely to have symptomatic recurrence compared to SEPS only cohort. Thus, MMA/SEPS appears to be a safe and equally effective minimally invasive treatment for cSDH patients with significant comorbidities who are poor surgical candidates.
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Affiliation(s)
- Austin Carpenter
- Georgetown University School of Medicine, 3900 Reservoir Road NW, Washington, DC, USA
| | - Mitchell Rock
- Georgetown University School of Medicine, 3900 Reservoir Road NW, Washington, DC, USA
| | - Ehsan Dowlati
- Department of Neurosurgery, MedStar Georgetown University Hospital, 3800 Reservoir Road NW, PHC7, Washington, DC, USA.
| | - Charles Miller
- Division of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Jeffrey C Mai
- Department of Neurosurgery, MedStar Georgetown University Hospital, 3800 Reservoir Road NW, PHC7, Washington, DC, USA.,Department of Neurosurgery, MedStar Washington Hospital Center, 110 Irving St. NW, Washington, DC, USA
| | - Ai-Hsi Liu
- Department of Radiology, MedStar Washington Hospital Center, 110 Irving St. NW, Washington, DC, USA
| | - Rocco A Armonda
- Department of Neurosurgery, MedStar Georgetown University Hospital, 3800 Reservoir Road NW, PHC7, Washington, DC, USA.,Department of Neurosurgery, MedStar Washington Hospital Center, 110 Irving St. NW, Washington, DC, USA
| | - Daniel R Felbaum
- Department of Neurosurgery, MedStar Georgetown University Hospital, 3800 Reservoir Road NW, PHC7, Washington, DC, USA.,Department of Neurosurgery, MedStar Washington Hospital Center, 110 Irving St. NW, Washington, DC, USA
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18
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Scerrati A, Pangallo G, Dughiero M, Mongardi L, Ricciardi L, Lofrese G, Dones F, Cavallo MA, De Bonis P. Influence of nutritional status on the clinical outcome of patients with chronic subdural hematoma: a prospective multicenter clinical study. Nutr Neurosci 2021; 25:1756-1763. [PMID: 33666524 DOI: 10.1080/1028415x.2021.1895480] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Elderly patients present a higher risk of developing chronic subdural hematomas (CSDHs) together with increased risk of malnutrition. The nutritional status may affect outcomes, response to treatments, and prognosis. Influence on other kinds of diseases was investigated showing an increased risk of mortality, morbidity, and adverse outcomes. However, no studies are available on its possible role for the outcome of patients with CSDH. This study aims to evaluate a possible relationship between the nutritional status and the clinical outcome of patients who underwent CSDH surgery. METHODS This is a multicenter prospective study enrolling all patients treated for CSDH. Demographic and clinical data were collected. For nutritional status evaluation, we used the Mini Nutritional Assessment (MNA). Chi-square test was used for comparing clinical variables of patients and logistic regression analysis was used for defining the impact of the aforementioned variables on the clinical outcome. RESULTS We enrolled 178 patients. Modified Rankin scale (mRS) was 0-2 pre-operatively in 23.6% of patients and post-operatively in 61.2% of patients. Total assessment MNA score was >23.5 in 47.8% of patients. Ninety-three patients (52.2%) presented a normal nutritional status, 63 (35.4%) were at risk of malnutrition and 22 (12.4%) were malnourished. The mean follow-up was 2.6 months. Malnourished patients were at higher risk of a worse outcome (OR 81; CI = 9-750). CONCLUSION This study suggests that nutritional status represents a strong predictor of outcome. Our results, albeit preliminary, demonstrated malnutrition is correlated to the risk of worse clinical outcome for patients undergoing surgery for chronic subdural hematoma. Further investigations with wider casuistry and multiple nutritional scores are required to validate our data.
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Affiliation(s)
- Alba Scerrati
- Department of Neurosurgery, Sant' Anna University Hospital, Ferrara, Italy.,Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - Giulia Pangallo
- Department of Neurosurgery, Sant' Anna University Hospital, Ferrara, Italy
| | - Michele Dughiero
- Department of Neurosurgery, Sant' Anna University Hospital, Ferrara, Italy
| | - Lorenzo Mongardi
- Department of Neurosurgery, Sant' Anna University Hospital, Ferrara, Italy
| | - Luca Ricciardi
- Neurosurgery Unit, Pia Fondazione di Culto e Religione Cardinal G. Panico, Tricase, Italy
| | - Giorgio Lofrese
- Neurosurgery Division, "M. Bufalini" Hospital, Cesena, Italy
| | - Flavia Dones
- Department of Neurosurgery, Sant' Anna University Hospital, Ferrara, Italy
| | - Michele Alessandro Cavallo
- Department of Neurosurgery, Sant' Anna University Hospital, Ferrara, Italy.,Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - Pasquale De Bonis
- Department of Neurosurgery, Sant' Anna University Hospital, Ferrara, Italy.,Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
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