Postoperative recurrence of chronic subdural hematoma is more frequent in patients with blood type A

Evaluation of clinical outcome and predictive factors for thromboembolism or hemorrhagic complications in patients treated for chronic subdural hematoma. A prospective observational study

The impact of anticoagulant and antiplatelet medications on clinical outcome and risk of complications is uncertain in chronic subdural hematoma (CSDH) patients. Currently, evidence-based guidelines and specific neurosurgical scores lacks. CHA₂DS₂-VASc and HAS-BLED scores have been proven to help predicting complications in the perioperative period of non-cardiac surgeries. We performed a multicenter prospective observational trial to evaluate the clinical outcomes and complications of CSDH patient undergoing surgery, comparing patients taking anticoagulant/antiplatelet (AAPT) and not (NT). Additionally, we investigated the role of CHA₂DS₂-VASc and HAS-BLED scores in predicting thromboembolic events or hemorrhages. No associations have been found between AAPT and clinical outcomes of patients. Emergency surgery was not a significant factor in improving outcomes. Post-operative hemorrhages were more frequent in the AAPT group, but none required a second surgery. A significant higher risk of of new bleedings was found in the ASA group with discontinuation ≤ 5 days. A higher HAS-BLED score was not associated with a worse clinical outcome. A 1-point increase in CHA₂DS₂-VASc was associated with a lower probability of favorable outcomes at 1 month. 90% of AAPT and 44% of NT patients were at moderate-high risk of thromboembolic events based on CHA₂DS₂-VASc score, with no difference in incidence between groups. The use of AAPT does not influence outcomes, complication rates, or recurrence in patients undergoing surgery for CSDH. Scores such as CHA₂DS₂-VASc or HAS-BLED could aid in stratifying bleeding and thromboembolic risks and in the management of these drugs in the perioperative period.

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

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

Eosinophil-Platelet Ratio as a Predictive Marker of the Postoperative Recurrence of a Chronic Subdural Hematoma

BACKGROUND AND OBJECTIVES

Symptomatic chronic subdural hematoma (CSDH) is caused by repetitive hemorrhage and inflammation, which is commonly treated with burr-hole surgery and has a relatively high postoperative recurrence rate. A decrease in the platelet count is indicative of a hemorrhagic tendency, while an increase in the eosinophil count is associated with inflammation. Assessing the balance between platelet-associated hemostasis and eosinophil-associated inflammation using the indeterminate biomarker, the eosinophil-platelet ratio (EPR), may be essential. Therefore, in this study, the accuracy of the EPR in predicting postoperative CSDH recurrence was evaluated and their correlation was determined.

METHODS

Data on symptomatic CSDHs of the cerebral hemisphere of patients who underwent burr-hole surgery at our institution between January 2013 and December 2022 were retrospectively reviewed. The EPR was calculated from preoperative peripheral blood examination data, and its correlation with postoperative CSDH recurrence was assessed. The hemispheres with CSDH were categorized into recurrence and nonrecurrence cohorts.

RESULTS

Data from 459 cerebral hemispheres of 405 patients with symptomatic CSDH were analyzed. In the 459 cerebral hemispheres with CSDH, 39 (8.5%) had postoperative recurrence. CSDH patients with a high EPR (≥1 × 10 -3 ) had a significantly higher recurrent rate than those with a low EPR (<1 × 10 -3 ) (15 of 86 [17.4%] vs 24 of 373 [6.4%], P = .002). In the modified Poisson regression analysis, the crude and adjusted risk ratios of high EPR were 2.79 (95% CI: 1.53, 5.09) and 2.62 (95% CI: 1.40, 4.89), respectively.

CONCLUSION

This study reveals that a high EPR is a useful predictive biomarker for postoperative CSDH recurrence. Cases of CSDH with a high EPR potentially require careful and close postoperative follow-up.

Combining Clinical-Radiomics Features With Machine Learning Methods for Building Models to Predict Postoperative Recurrence in Patients With Chronic Subdural Hematoma: Retrospective Cohort Study

BACKGROUND

Chronic subdural hematoma (CSDH) represents a prevalent medical condition, posing substantial challenges in postoperative management due to risks of recurrence. Such recurrences not only cause physical suffering to the patient but also add to the financial burden on the family and the health care system. Currently, prognosis determination largely depends on clinician expertise, revealing a dearth of precise prediction models in clinical settings.

OBJECTIVE

This study aims to use machine learning (ML) techniques for the construction of predictive models to assess the likelihood of CSDH recurrence after surgery, which leads to greater benefits for patients and the health care system.

METHODS

Data from 133 patients were amassed and partitioned into a training set (n=93) and a test set (n=40). Radiomics features were extracted from preoperative cranial computed tomography scans using 3D Slicer software. These features, in conjunction with clinical data and composite clinical-radiomics features, served as input variables for model development. Four distinct ML algorithms were used to build predictive models, and their performance was rigorously evaluated via accuracy, area under the curve (AUC), and recall metrics. The optimal model was identified, followed by recursive feature elimination for feature selection, leading to enhanced predictive efficacy. External validation was conducted using data sets from additional health care facilities.

RESULTS

Following rigorous experimental analysis, the support vector machine model, predicated on clinical-radiomics features, emerged as the most efficacious for predicting postoperative recurrence in patients with CSDH. Subsequent to feature selection, key variables exerting significant impact on the model were incorporated as the input set, thereby augmenting its predictive accuracy. The model demonstrated robust performance, with metrics including accuracy of 92.72%, AUC of 91.34%, and recall of 93.16%. External validation further substantiated its effectiveness, yielding an accuracy of 90.32%, AUC of 91.32%, and recall of 88.37%, affirming its clinical applicability.

CONCLUSIONS

This study substantiates the feasibility and clinical relevance of an ML-based predictive model, using clinical-radiomics features, for relatively accurate prognostication of postoperative recurrence in patients with CSDH. If the model is integrated into clinical practice, it will be of great significance in enhancing the quality and efficiency of clinical decision-making processes, which can improve the accuracy of diagnosis and treatment, reduce unnecessary tests and surgeries, and reduce the waste of medical resources.

Comparison of outcomes and recurrence rates in patients undergoing single or double burr hole surgery for the treatment of chronic subdural hematoma in Bosnia and Herzegovina

Introduction

Chronic subdural hematoma (CSDH) is a prevalent condition commonly seen in elderly individuals, often requiring neurosurgical intervention.

Research question

This study investigates patient characteristics and recurrence rates in CSDH patients treated with single or double burr hole surgery in Bosnia and Herzegovina. Methods: A retrospective study was conducted on patients treated for CSDH between January 2018 and December 2022. The diagnosis of CSDH was confirmed through preoperative CT or MRI of the brain. Patients underwent either single or double burr hole surgery based on the neurosurgeon's decision. Preoperative and postoperative brain CT scans, along with clinical outcomes, were analyzed.

Results

A total of 87 patients were included in the study, with 102 burr hole surgeries performed. Among these, 49 patients received single burr hole surgery, while 53 patients underwent double burr hole surgery. Recurrence of CSDH occurred in 8.8% of cases, with no significant difference observed between the groups. Notably, single burr hole surgery demonstrated comparable efficacy to double burr hole surgery in terms of subdural reduction and occurrence of pneumocephalus, while exhibiting fewer complications and shorter hospitalization.

Discussion and conclusions

burr hole surgery, whether performed as a single or double procedure, is an effective treatment option for CSDH, as it leads to positive outcomes in both radiological and clinical assessments of patients following surgery. The population of Bosnia and Herzegovina receives good neurosurgical care for CSDH.

Advances in pathogenic mechanisms, diagnostic methods, surgical and non-surgical treatment, and potential recurrence factors of Chronic Subdural Hematoma: A review

Chronic Subdural Hematoma (CSDH) is a common hemorrhagic disease in neurosurgery, and with the intensification of global aging, its incidence is gradually increasing. With the advancement of scientific technology, the etiological concepts and surgical treatments for CSDH have continually evolved over time. Currently, neuroscientists' understanding of CSDH is no longer confined to bridging vein rupture; exploration of various mechanisms such as angiogenesis, maturation of blood vessels, and inflammation is also underway. In-depth exploration and discovery of pathogenic mechanisms guide the updating of clinical treatment strategies and methods. For different types of CSDH, there is now a clear guidance for the targeted selection of treatment methods. However, the current treatment of CSDH cannot completely solve all problems, and the updating of treatment methods as well as the development and validation of new effective drugs remain challenges for the future. In addition, the recurrence of CSDH is a significant issue that needs to be addressed. Although we have reviewed potential recurrent factors that may be associated, the strength of this evidence is insufficient. Future research should gradually focus on validating these recurrent factors and exploring new ones, in order to optimize the existing understanding and treatment of CSDH.

Effect of decreased platelets on postoperative recurrence of chronic subdural hematoma

Introduction

Chronic subdural hematoma (CSDH) is commonly treated using simple burr hole surgery. However, postoperative recurrence occurs at a relatively high rate of 10-20%. A decrease in platelet count (PC) may be associated with recurrence via a hemostasis disorder; however, this association has not been well-studied. Therefore, this study aimed to investigate the association between PC and postoperative CSDH recurrence.

Methods

We retrospectively reviewed the data for CSDHs in 488 cerebral hemispheres of 431 patients who underwent burr hole surgery at our institution between January 2013 and December 2022. The association between preoperative PC and postoperative CSDH recurrence was investigated. We used the first quartile of PC, PC < 170 × 103/μL to define a threshold for decreased PC.

Results

In total, 459 cerebral hemispheres with CSDHs in 405 patients were followed up postoperatively for at least 3 months or until CSDH disappeared. CSDH recurred in 39 (8.5%) cerebral hemispheres. The recurrence rate was gradually increased in parallel with a decreasing PC. Among 109 CSDHs with a decreased PC (<170 × 103/μL), 15 (13.8%) recurred, whereas only 24 (6.9%) of 350 CSDHs without a decreased PC recurred (p = 0.03). In univariable logistic analysis, eosinophil-rich blood (≥100/μL eosinophils in peripheral blood) and a decreased PC were significant risk factors. Multivariable analysis showed that eosinophil-rich blood (adjusted odds ratio, 2.51; 95% confidence interval, 1.26-4.99; p = 0.009) and a decreased PC (adjusted odds ratio, 2.15; 95% confidence interval, 1.07-4.35; p = 0.03) were independent risk factors for recurrence.

Conclusion

Our study showed that a decrease in PC was associated with postoperative CSDH recurrence. Patients with CSDH and a decreased PC require careful postoperative follow-up.

Inflammatory human leucocyte antigen genotypes are not a risk factor in chronic subdural hematoma development

BACKGROUND

Chronic subdural hematoma (CSDH) pathophysiology has undergone a paradigm shift from being regarded as solely traumatic to be driven mainly by inflammation. Human leucocyte antigen (HLA) is a gene complex involved in antigen processing and presentation to T lymphocytes, thereby mediating the adaptive immune responses. As specific HLA profiles are associated with inflammatory diseases, patients with a specific HLA profile may have a lower threshold for subdural inflammation, and therefore are predisposed for CSDH development. We hypothesized that (1) CSDH patients have a specific HLA profile compared to a Danish background population, and (2) patients with recurrent CSDH have a specific HLA profile compared to CSDH patients without recurrent CSDH.

METHODS

Three specific HLA class II haplotypes known to drive inflammatory-mediated diseases were determined in 68 patients with CSDH. The distribution of these three haplotypes in our CSDH population was compared to a Danish population of blood donors using Monte Carlo Pearson's chi-square test. Furthermore, the distribution of the haplotypes was compared between CSDH patients with and without recurrent CSDH.

RESULTS

We found no significant association between either of the haplotypes and the risk of CSDH, and neither of the haplotypes were associated with increased risk of CSDH recurrence.

CONCLUSION

This study did not show an association between selected HLA class II haplotypes and the risk of CSDH or recurrence of CSDH compared with a healthy background population.

Preoperative elevated eosinophils in peripheral blood for prediction of postoperative recurrence of chronic subdural hematoma

OBJECTIVE

Chronic subdural hematoma (CSDH) is a common neurological disease with a significant postoperative recurrence rate. There are numerous reported studies of the development of CSDH. In recent years, fibrinolysis, angiogenesis, and inflammation have all been identified as relevant factors in the development of CSDH. While several authors have reported risk factors associated with CSDH recurrence, differential blood count of leukocytes has not yet been discussed. Therefore, in this study the authors aimed to retrospectively investigate the association between differential blood leukocyte count and the rate of CSDH recurrence.

METHODS

The authors retrospectively reviewed 476 patients with 529 CSDHs who underwent surgery at a single institution between January 2011 and December 2021. After exclusion of patients who had not undergone a differential blood test of leukocytes preoperatively, CSDHs in 517 cerebral hemispheres of 466 patients were included in the study. Peripheral blood eosinophil counts ≥ 100/µL were considered eosinophil rich.

RESULTS

CSDHs in 494 cerebral hemispheres of 445 patients were followed up postoperatively for at least 3 months or until resolution indicated by CSDH disappearance. Postoperative recurrence of CSDH was observed in 46 cerebral hemispheres (9.3%). Among the preoperative differential blood counts of all leukocytes, eosinophils alone were significantly associated with CSDH recurrence (median [IQR] 76/µL [30-155/µL] vs 119/µL [39-217/µL]; p = 0.03). Multivariable regression analysis showed thrombocytopenia (adjusted OR [aOR] 5.23, 95% CI 1.85-14.79; p = 0.002), use of anticoagulant drugs (aOR 2.51, 95% CI 1.17-5.38; p = 0.02), hematoma volume (10 mL per increase) (aOR 1.08, 95% CI 1.00-1.16; p = 0.04), and eosinophil-rich peripheral blood (aOR 2.22, 95% CI 1.17-4.23; p = 0.02) were all independent predictors for CSDH recurrence.

CONCLUSIONS

This study showed that preoperative peripheral blood eosinophil count was an independent risk factor for CSDH recurrence. Therefore, patients with CSDH who have elevated eosinophils preoperatively in peripheral blood require careful follow-up.

Correlation between Blood Type 0 and Risk of Chronic Subdural Hematoma Recurrence: A Single Center Retrospective Cohort Study

Chronic subdural hematoma (cSDH) is a common disease in the neurological and neurosurgical world. The recommended treatment for cSDH patients with moderate or severe neurological symptoms is surgical evacuation, but cSDH frequently recurs. The patient’s ABO blood type may influence the outcome. This study aims to evaluate the correlation between cSDH recurrence and blood type O. We performed a retrospective analysis of the data of patients with cSDH who were surgically treated. Recurrence was defined as the need for re-operation within the first 12 weeks after the initial surgery. We analyzed standard demographic data, duration and type of surgery, ABO blood types, and the re-operation rate. Univariate and multivariate analyses were conducted. A total of 229 patients were included. The recurrence of hematoma was identified in 20.5% of patients. Blood type O was found to be significantly associated with cSDH recurrence leading to re-operation within 12 weeks (p = 0.02, OR 1.9, 95% CI 1.1–3.5). Thrombocyte aggregation inhibition and oral anticoagulants were not predictors of cSDH recurrence. Patients with blood type O in our cohort were identified to be at higher risk of cSDH recurrence and may, therefore, be a more vulnerable patient group. This finding needs further evaluation in larger cohorts.

Sequential Middle Meningeal Artery Embolization after Burr Hole Surgery for Recurrent Chronic Subdural Hematoma

Middle meningeal artery embolization (MMAE) for chronic subdural hematoma (CSDH) is a novel, minimally invasive treatment. The indications and treatment practices for MMAE are variable and remain controversial. This study aimed to evaluate a strategy involving sequential MMAE after burr hole surgery for treating recurrent CSDH. We performed a retrospective analysis of data from consecutive patients who had undergone MMAE using liquid embolic agents within approximately 2 weeks after burr hole surgery for recurrent CSDH from September 2020 to March 2022. We analyzed patient characteristics, procedural details, CSDH recurrence after MMAE, surgical rescue, and complications. Six of the nine patients who underwent MMAE for CSDH recurrence were male, and the median age was 85 (range, 70-94) years. Five of the nine patients were being administered antithrombotic agents. The median duration between the burr hole surgery and MMAE procedure was 10 (range, 3-25) days. Anterior and posterior convexity branches were targeted for embolization using low-concentration N-butyl cyanoacrylate (NBCA), and the abnormal vascular networks with a cotton wool appearance disappeared after embolization in all cases. The NBCA distribution was observed by high-resolution computed tomography during the procedure; in three of nine cases, the NBCA penetrated not only the MMA but also the inner membrane. No recurrence, surgical rescue, or complications were observed in any patient during the median follow-up period of 3 months. As a minimally invasive treatment for recurrent CSDH, sequential MMAE after burr hole surgery may be a safe and effective option for preventing recurrence.

Peripheral blood eosinophil and classification of residual hematoma help predict the recurrence of chronic subdural hematoma after initial surgery

Chronic subdural hematoma (CSDH) is a common type of intracranial hemorrhage in neurosurgical practice, whose incidence has increased markedly in recent years. However, CSDH still troubles clinicians with a high postoperative recurrence rate. The presence of eosinophils has been confirmed in some CSDH surgical specimens. Furthermore, postoperative residual hematoma has not been classified, and its association with the recurrence of CSDH remains unknown. The present study aimed to test the hypothesis that the peripheral blood eosinophils and the classification of postoperative residual hematoma are significant for the prediction of CSDH recurrence after burr-hole surgery. A retrospective review of 258 CSDH patients who received burr-hole surgery was performed. A complete blood picture with differential count was taken before surgery. Clinical, laboratory, and radiographic factors predicting CSDH recurrence were identified in univariable and multivariable analyses. Univariable analysis showed that the percentage of eosinophils, peripheral blood eosinophil count <0.15 × 10⁹/L, gradation and separated types, postoperative volume of the residual cavity ≥70 ml, residual air volume ≥28 ml, residual hematoma volume ≥55 ml, residual hematoma width ≥1.4 cm, postoperative midline shift ≥5.6 mm, postoperative brain re-expansion rate <41%, postoperative low-density type, and postoperative high-density type correlated with the recurrence of CSDH. Multivariable analysis, however, showed that peripheral blood eosinophil count <0.15 × 10⁹/L, gradation and separated types, preoperative midline shift ≥9.5 mm, postoperative brain re-expansion rate <41%, postoperative low-density type, and postoperative high-density type are independent predictors for the recurrence of CSDH. We expect that peripheral blood eosinophils and the classification of postoperative residual hematoma may facilitate our understanding of the recurrence of CSDH after initial surgery.

Solve the post-operative subdural pneumatosis of chronic subdural hematoma: A novel active bone hole drainage system

Background

Post-operative subdural pneumatosis (PSP) is commonly encountered after the chronic subdural hematoma (CSDH) surgery which currently lacks effective methods to avoid the condition. This study invented an active bone hole drainage system to change the venting technique with the aim of comparing post-operative efficacy and prognosis to traditional drilling and drainage.

Methods

We conducted a randomized controlled trial between January 2020 and January 2021. A total of 86 patients undergoing surgery were assessed for eligibility, with 50 patients randomly assigned to the control group (received drilling and drainage) and 36 patients to the test group (received modified surgery). The 6-month follow-up was done after surgery. CSDH recurrence and post-operative hematoma re-increasement were the primary endpoints. The data from the two groups were compared and analyzed. This study was registered with the Chinese Clinical Trials Register (ChiCTR2200057158), and had ethics committee approval and patient consent.

Results

The incidence of PSP in the test group (0%, 0/30)was lower than the control group (93.88%, 46/49) (P &lt; 0.001). The brain non-expansion rates 3 days/weeks/months after surgery of the test group were 59.25 [49.62, 76.97], 52.10 [42.88, 72.45], and 29.45 [23.40, 36.95] respectively, which were lower than the control group which were 78.60 [69.50, 94.70], 73.10 [60.70, 87.40], and 61.70 [51.50, 78.30], respectively (P &lt; 0.001). The ADL scores a week/month/3/6 months after surgery of the test group were 100.00 [60.00, 100.00], 100.00 [85.00, 100.00], 100.00 [100.00, 100.00], 100.00 [100.00, 100.00], which were better than the control group's 60.00 [60.00, 80.00], 75.00 [60.00, 100.00], 100.00 [60.00, 100.00], 100.00 [60.00, 100.00] (P &lt; 0.05). The incidence of primary endpoints in the test group (10%, 3/30) was lower than the control group (34.69%, 17/49) (P &lt; 0.05).

Conclusions

Compared to drilling and drainage, the modified surgery with the active bone hole drainage system significantly reduced the incidence of PSP and primary endpoints and improved the post-operative efficacy and prognosis.

Clinical trial registration

Identifier: ChiCTR2200057158.

Recurrence of Chronic Subdural Hematoma Is Independent of ABO Blood Type: A Retrospective Cohort Study

Objective

A previous study with a limited number of patients has shown that blood type A was a risk factor in the recurrence of CSDH. The primary objective of this study was to investigate the association between the recurrence of CSDH and ABO blood type based on a larger sample size.

Methods

The authors reviewed in-patients with symptomatic CSDH from August 2011 to August 2021. Hospitalization information and data on long-term outcomes and recurrence among these patients were gathered. For all clinical variables, numbers (percentages) and mean ± standard deviations were used for categorical and continuous variables, respectively. For intergroup comparisons, the χ2 test or one-way ANOVA was carried out. Multivariable logistic regression analyses were performed to identify the association between CSDH recurrence and blood types.

Results

We included 1,556 inpatients in this study. The recurrence rate of CSDH showed no differences among different blood types. In the multivariable logistic regression analyses, ABO blood type (A: OR, 1.064; 95% CI, 0.467-2.851, p = 0.793; B: OR, 0.682, 95% CI, 0.315-1.269, p = 0.164; AB: OR, 0.537, 95% CI, 0.426-1.861, p = 0.357) was not a significantly independent predictor of CSDH recurrence.

Conclusions

Our study demonstrated that ABO blood type was not a risk factor in the recurrence of CSDH. Thus, we should not pay too much attention to ABO blood type in terms of CSDH recurrence.