Why do chronic subdural hematomas continue to grow slowly and not coagulate? Role of thrombomodulin in the mechanism

Post-traumatic hematoma of the "transdural" virtual space. A possible cause of incorrect surgical treatment of epidural hematomas

The space existing between the external and internal dural layer has been anatomically described as a virtual space; no clear clinical significance has been given to it to date. We hereby describe a case of a child with what was expected to be a purely epidural hematoma, at surgery, was found to be composed of two equally coexistent components, one in the epidural space and the second one between the two dural layers. The recognition of a possible involvement of the transdural space in the case of post-traumatic epidural hematomas is relevant for a correct conclusion of the surgical treatment of epidural hematomas, extensively considered basic practice among neurosurgical procedures.

Liquid embolic surface area as a predictor of chronic subdural hematoma resolution in middle meningeal artery embolization

BACKGROUND

Liquid embolic agents (LEAs) such as ethylene vinyl alcohol (EVOH) are utilized for middle meningeal artery embolization (MMAE) for chronic subdural hematomas (cSDH). LEAs may be advantageous for MMAE as they are permanent and can penetrate the microvasculature of the subdural membranes. LEA surface area (SA) can quantify this penetration. The segmentation of LEA SA is not described in the literature and may be of interest in refining MMAE technique.

METHODS

We retrospectively collected computerized tomography (CT) scans from 74 patients (with 95 cSDH) who underwent first-line MMAE with EVOH. Non-contrast head CTs were acquired pre-embolization, immediately post-embolization and at 1-, 3-, and 6 month follow-up. A 3D-Slicer was used to segment hematoma volumes and the liquid embolic cast. We hypothesized that greater LEA SA would be correlated with greater improvements in cSDH volumetric resolution.

RESULTS

There was significant resolution in cSDH volumes over the follow-up period compared to preoperative volume (p<0.0001). The LEA SA was significantly correlated with the rate of cSDH resolution at 3 months (R2=0.08, p=0.03), and 6 months (R2=0.14, p=0.01).

CONCLUSIONS

The correlation of LEA surface area with hematoma resolution at 3-months and 6-months suggests greater LEA penetration may improve radiographic outcomes. This study uniquely provides a quantitative radiological perspective on the effect of LEA penetration on cSDH resolution.

Non-surgical management of chronic subdural hematoma: insights and future perspectives from an international survey including neurosurgeons from 90 countries worldwide

BACKGROUND

Chronic subdural hematoma (cSDH) is one of the most common neurosurgical conditions. Although surgical evacuation is still the gold standard for treatment, recent advances have led to the development of other management strategies, such as medical therapies and endovascular middle meningeal artery (MMA) embolization. Through this international survey, we investigated the global trends in cSDH management, focusing on medical and endovascular treatments.

DESIGN AND PARTICIPANTS

A 14-question, web-based, anonymous survey was distributed to neurosurgeons worldwide.

RESULTS

Most responders do not perform MMA embolization (69.5%) unless for specific indications (29.6%). These indications include residual cSDH after surgical evacuation (58.9%) or cSDH in patients on antiplatelet medications to avoid surgical evacuation (44.8%). Survey participants from teaching versus non-teaching hospitals (p = 0.002), public versus private hospitals (p = 0.022), and Europe versus other continents (p < 0.001) are the most users of MMA embolization. A large number of participants (51%) declare they use a conservative/medical approach, mainly to avoid surgery in patients with small cSDH (74.8%).

CONCLUSIONS

This survey highlights the current trends of cSDH management, focusing on conservative and MMA embolization treatment strategies. Most responders prefer a conservative approach for patients with small cSDHs not requiring surgical evacuation. However, in higher-risk scenarios such as residual hematomas after surgery or patients on antiplatelet medications, MMA embolization is regarded as a reasonable option by participants. Future studies should clarify the indications of MMA embolization, including appropriate patient selection and efficacy as a stand-alone procedure.

Factors for predicting recurrence after burr hole drainage for chronic subdural hematoma: a retrospective study

Chronic subdural hematoma (SDH) is a common disease in the neurosurgical field, and hematoma drainage through burr hole trephination has been widely considered the optimal treatment for SDH. Despite numerous investigations aimed at predicting recurrence rates and associated factors, studies have demonstrated inconsistent results. In this study, we aimed to comprehensively determine the predictive factors of chronic SDH recurrence in surgically treated patients. We retrospectively evaluated 578 consecutive patients who underwent single burr hole surgery for chronic SDH at our institute between January 2008 and December 2021. Various clinical and radiological factors in patients with and without recurrence were compared using univariate and multivariate logistic regression analyses. A total of 438 patients (531 hemispheres) were analyzed. Fifty-four (10.17%) of the 531 hemispheres had recurrence of chronic SDH within 6 months. Male sex (adjusted odds ratio (aOR) = 3.48; 95% confidence interval (CI), 1.42-8.49), bilateral hematomas (aOR = 2.14; 95% CI, 1.05-4.35), laminar hematoma type (aOR = 2.87; 95% CI, 1.23-6.71), > 30-cm3 volume of postoperative residual hematoma (aOR = 2.99; 95% CI, 1.01-8.83), and preoperative blood glucose level of ≥ 150 mg/dL (aOR = 2.11; 95% CI, 1.10-4.05) were identified as independent factors associated with recurrence in multivariate logistic regression analysis. The present study revealed that male patients and those who had bilateral hematomas, laminar hematoma type, a large volume of hematoma after surgery, and a high preoperative blood glucose level had a higher probability of experiencing recurrent chronic SDH. We recommend close monitoring of patients 6 months postoperatively to detect subsequent chronic SDH recurrence.

Application of Hemoperfusion in the Treatment of Acute Poisoning

Rescue of acute poisoning is a race against time, and it is particularly important to remove toxic substances in time. Traditional methods include gastric lavage, promoting elimination, chelating agents, and other treatments. Hemoperfusion is a common blood purification technique. In the clinical practice of acute poisoning, hemoperfusion can directly remove toxic substances through its unique adsorption effect, showing its excellent efficacy. This paper reviews the experience of hemoperfusion in the treatment of various drug overdoses, pesticides, biological toxins, and industrial poisons, even drug addiction. It is hoped to provide a reference for clinicians in acute poisoning rescue.

Middle Meningeal Artery Embolization for Chronic Subdural Hematoma: An Analysis of 35 Consecutive Patients

INTRODUCTION

There is sufficient scientific literature that demonstrates favorable outcomes using the minimally invasive technique of middle meningeal artery embolization (MMAE) for the treatment of chronic subdural hematomas (cSDH). The authors evaluate the outcomes of 35 consecutive patients treated with MMAE, both with and without adjuvant surgical drainage (ASD), in an attempt to identify variables that may affect the outcome of patients treated with MMAE for cSDH.

METHODS

A multivariate retrospective analysis was performed on patients who received MMAE for cSDH, including age, size of cSDH, ASD, presence of unilateral or bilateral collections, and use of anticoagulants.

RESULTS

Twenty patients underwent MMAE with planned ASD, while 15 patients had MMAE only; these groups had an average cSDH size reduction (measured at its greatest width) of 74% and 69% of cSDH, respectively. Of the 15 patients who were initially treated only with MMAE, three (20%) required a rescue craniotomy. Twenty patients (57%) who had initially presented while receiving oral anticoagulants had an average of 71% size reduction with ASD compared to 74% reduction in those without ASD. Patients not using anticoagulants had an 84% and 78% average reduction in size, respectively. Twelve patients presented with bilateral cSDH; patients who received ASD had an average size reduction of 58%; those without ASD had 63%. Patients with unilateral cSDH had 85% and 83% reduction in size, respectively.

CONCLUSION

Middle meningeal artery embolization, with or without ASD, can be a useful alternative or adjunct to standard surgical treatment for cSDH. Our study found that only three of 35 patients (9%) treated with this method required any further surgical intervention. No patient who received ASD had a recurrence of their cSDH. Further investigation, including prospective randomized studies, would be useful to better identify which patients can benefit and variables that impact the outcome of patients undergoing MMAE.

Endoscopic Treatment of Chronic Subdural Hematoma Combined with Inner Subdural Hygroma

OBJECTIVE

A chronic subdural hematoma (CSDH) is a collection of bloody fluid located in the subdural space and encapsulated by neo-membranes. An inner subdural hygroma (ISH) is observed between the inner membrane of a CSDH and the brain surface. We present six cases of CSDH combined with ISH treated via endoscopy.

METHODS

Between 2011 and 2022, among the 107 patients diagnosed with CSDH in our institute, six patients were identified as presenting with CSDH combined with ISH and were included in this study. Preoperative computerized tomography (CT) and magnetic resonance imaging (MRI) were performed simultaneously, and endoscopic surgery for aspiration of the hematoma was performed in all cases of CSDH combined with ISH.

RESULTS

The mean age of patients was 71 years (range, 66 to 79). The patients were all male. In two cases, the ISH was not identified on CT, but was clearly seen on MRI in all patients. The inner membrane of the CSDH was tense and bulging after draining of the CSDH in endoscopic view due to the high pressure of the ISH. After fenestration of the inner membrane of the CSDH and aspiration of the ISH, the membrane was sunken down due to the decreasing pressure of the ISH. There was one recurrence in post-operative 2-month follow up. The symptoms improved in all patients after surgery, and there were no surgery-related complications.

CONCLUSION

CSDH combined with ISH can be diagnosed on imaging, and endoscopic surgery facilitates safe and effective treatment.

Does a negative correlation of heme oxygenase-1 with hematoma thickness in chronic subdural hematomas affect neovascularization and microvascular leakage? A retrospective study with preliminary validation

OBJECTIVE

Chronic subdural hematoma (CSDH) is a common neurological disease among elderly adults. The progression of CSDH is an angiogenic process, involving inflammatory mediators that affect vascular permeability, microvascular leakage, and hematoma thickness. The authors aimed to identify biomarkers associated with angiogenesis and vascular permeability that might influence midline shift and hematoma thickness.

METHODS

Medical records and laboratory data of consecutive patients who underwent surgery for CSDH were analyzed. Collected data were basic demographic data, CSDH classification, CSDH thickness, midline shift, heme oxygenase-1 (HO-1) levels in hematomas, and common laboratory markers. Linear regression analysis was used to evaluate the relationship of CSDH thickness with characteristic variables. The chick chorioallantoic membrane (CAM) assay was used to test the angiogenic potency of identified variables in ex ovo culture of chick embryos.

RESULTS

In total, 93 patients with CSDH (71.0% male) with a mean age of 71.0 years were included. The mean CSDH thickness and midline shift were 19.7 and 9.8 mm, respectively. The mean levels of HO-1, ferritin, total bilirubin, white blood cells, segmented neutrophils, lymphocytes, platelets, international normalized ratio, and partial thromboplastin time were 36 ng/mL, 14.8 μg/mL, 10.5 mg/dL, 10.3 × 103 cells/μL, 69%, 21.7%, 221.1 × 109 cells/μL, 1.0, and 27.8 seconds, respectively. Pearson correlation analysis revealed that CSDH thickness was positively correlated with midline shift distance (r = 0.218, p < 0.05) but negatively correlated with HO-1 concentration (r = -0.364, p < 0.01) and ferritin level (r = -0.222, p < 0.05). Multivariate linear regression analysis revealed that HO-1 was an independent predictor of CSDH thickness (β = -0.084, p = 0.006). The angiogenic potency of HO-1 in hematoma fluid was tested with the chick CAM assay; topical addition of CSDH fluid with low HO-1 levels promoted neovascularization and microvascular leakage. Addition of HO-1 in a rescue experiment inhibited CSDH fluid-mediated angiogenesis and microvascular leakage.

CONCLUSIONS

HO-1 is an independent risk factor in CSDH hematomas and is negatively correlated with CSDH thickness. HO-1 may play a role in the pathophysiology and development of CSDH, possibly by preventing neovascularization and reducing capillary fragility and hyperpermeability.

Biofluid Biomarkers in the Prognosis of Chronic Subdural Hematoma: A Systematic Scoping Review

The present systematic scoping review aimed at mapping and analyzing the available literature on biological fluid (biofluid) biomarkers showing promise in the prediction of chronic subdural hematoma (cSDH) recurrence and the prognosis of neurological/functional patient outcome. Twenty-three studies published between 2003 and 2023 investigating a diverse range of biomarkers in hematoma fluid and/or the circulation in 3749 patients were included. Immune cell populations and inflammatory/anti-inflammatory cytokines comprised the most studied category of biomarkers displaying significant findings. A notable time trend in biomarker studies was a recent shift in research focus towards the analysis of circulating biomarkers. Several biomarkers were indicated as independent predictors of cSDH recurrence and/or functional/neurological outcome, including circulating fibrinogen degradation products (FDP), brain natriuretic peptide (BNP-1) and high-density lipoprotein (HDL), as well as blood urea nitrogen (BUN) and the ratios of blood neutrophil to lymphocyte (NLR) or red blood cell distribution width to platelet count (RPR). While studies on cSDH prognostic biomarkers have gained, in recent years, momentum, additional multicenter prospective studies are warranted to confirm and extend their findings. The identification of prognostic biofluid biomarkers in cSDH is an active field of research that may provide future tools, guiding clinical decisions and allowing for the design of treatments based on risk stratification.

Incidence of Chronic Subdural Hematoma after Mild Head Trauma in Elderly Patients with or without Pre-traumatic Conditioning of Anti-thrombotic Drugs

Anti-thrombotic drugs may increase the risk for chronic subdural hematoma (CSDH). However, whether to continue or discontinue/counteract these drugs has not been investigated in patients with mild head trauma. CSDH incidence after mild head trauma, as well as the risk for CSDH in patients with anti-thrombotic drugs, were investigated in this study. The study included 765 consecutive elderly (>65 y.o.) patients with mild head trauma and an initial Glasgow Coma Scale (GCS) score of 14 or 15. All patients received initial CT within 24 hours after trauma and were re-examined 30 days after trauma to detect CSDH formation, repeating for every 30 days to examine symptomatic CSDH progression. Patients were divided into two groups, with anti-thrombotic drugs (n = 195) or without them (n = 263), to investigate the influence of pre-traumatic conditioning with anti-thrombotic drugs on CSDH. The whole sample was 458 out of 765 cases. The incidence of CSDH formation was 91 out of 458 cases (19.9%) after mild head trauma, with no significant difference between with and without anti-thrombotic drugs. CSDH progressed as symptomatic in 21 out of 458 cases (4.6%), with no significant difference between with and without anti-thrombotic drugs. Pre-traumatic conditioning with anti-thrombotic drugs and its continuation after trauma did not affect the incidence of formation or symptomatic progression of CSDH. This finding suggests that discontinuing and/or counteracting anti-thrombotic drugs may be unnecessary in patients with mild head trauma.

Autotaxin Activity in Chronic Subdural Hematoma: A Prospective Clinical Study

Autotaxin (ATX) is the ectoenzyme producing the bulk of lysophosphatidic acid (LPA) in circulation. ATX and LPA-mediated signaling (the ATX-LPA axis) play critical roles in the vascular and nervous system development. In adults, this axis contributes to diverse processes, including coagulation, inflammation, fibroproliferation and angiogenesis under physiological and/or pathophysiological conditions. Given evidence implicating several of these processes in chronic subdural hematoma (CSDH) pathogenesis and development, we assessed ATX activity in CSDH patients. Twenty-eight patients were recruited. Blood and hematoma fluid were collected. Enzymatic assays were used to establish serum and hematoma ATX activity. Enzyme-linked immunosorbent assays were used to establish hematoma beta trace (BT) levels, a cerebrospinal fluid (CSF) marker, in a hematoma. ATX activity was nearly three folds higher in hematoma compared to serum (P < 0.001). There was no significant correlation between BT levels and ATX activity in a hematoma. The present results show, for the first time, that ATX is catalytically active in the hematoma fluid of CSDH patients. Moreover, our findings of significantly elevated ATX activity in hematoma compared to serum, implicate the ATX-LPA axis in CSDH pathophysiology. The CSF origin of ATX could not be inferred with the present results. Additional research is warranted to establish the significance of the ATX-LPA axis in CSDH and its potential as a biomarker and/or therapeutic target.

Is external hydrocephalus a possible differential diagnosis when child abuse is suspected?

Background

Criteria for diagnosing abusive head trauma (AHT) or “shaken baby syndrome” are not well defined; consequently, these conditions might be diagnosed on failing premises.

Methods

The authors have collected a total of 28 infants, from the US (20) and Norway (8), suspected of having been violently shaken, and their caregivers had been suspected, investigated, prosecuted or convicted of having performed this action. Among 26 symptomatic infants, there were 18 boys (69%) and 8 girls (31%)—mean age 5.1 month, without age difference between genders.

Results

Twenty-one of 26 symptomatic children (81%) had a head circumference at or above the 90 percentile, and 18 had a head circumference at or above the 97 percentile. After macrocephaly, seizure was the most frequent initial symptom in 13 (50%) of the symptomatic infants. Seventeen (65%) of the symptomatic infants had bilateral retinal haemorrhages, and two had unilateral retinal haemorrhages. All infants had neuroimaging compatible with chronic subdural haematomas/hygromas as well as radiological characteristics compatible with benign external hydrocephalus (BEH).

Conclusions

BEH with subdural haematomas/hygromas in infants may sometimes be misdiagnosed as abusive head trauma. Based on the authors’ experience and findings of the study, the following measures are suggested to avoid this diagnostic pitfall: medical experts in infant abuse cases should be trained in recognising clinical and radiological BEH features, clinicians with neuro-paediatric experience should always be included in the expert teams and reliable information about the head circumference development from birth should always be available.

Effectiveness Comparisons of Drug Therapy on Chronic Subdural Hematoma Recurrence: A Bayesian Network Meta-Analysis and Systematic Review

Objectives: We aim to compare the effectiveness of different drug treatments in improving recurrence in patients with chronic subdural hematoma (CSDH).

Methods: Eligible randomized controlled trials (RCTs) and prospective trials were searched in PubMed, Cochrane Library, and Embase, from database inception to December 2021. After the available studies following inclusion and exclusion criteria were screened, the main outcome measures were strictly extracted. Taking the random-effects model, dichotomous data were determined and extracted by odds ratio (OR) with 95% credible interval (CrI), and a surface under the cumulative ranking curve (SUCRA) was generated to calculate the ranking probability of comparative effectiveness among each drug intervention. Moreover, we used the node-splitting model to evaluate inconsistency between direct and indirect comparisons of our network meta-analysis (NMA). Funnel plots were used to evaluate publication bias.

Results: From the 318 articles found during initial citation screening, 11 RCTs and 3 prospective trials (n = 3,456 participants) were ultimately included in our study. Our NMA results illustrated that atorvastatin + dexamethasone (ATO+DXM) (OR = 0.06, 95% CrI 0.01, 0.89) was the most effective intervention to improve recurrence in patients with CSDH (SUCRA = 89.40%, 95% CrI 0.29, 1.00). Four drug interventions [ATO+DXM (OR = 0.06, 95% CrI 0.01, 0.89), DXM (OR = 0.18, 95% CrI 0.07, 0.41), tranexamic acid (TXA) (OR = 0.26, 95% CrI 0.07, 0.41), and ATO (OR = 0.41, 95% CrI 0.12, 0.90)] achieved statistical significance in improving recurrence in CSDH patients compared with the placebo (PLB) or standard neurosurgical treatment (SNT) group.

Conclusion: Our NMA showed that ATO+DXM, DXM, ATO, and TXA had definite efficacy in improving recurrence in CSDH patients. Among them, ATO+DXM is the best intervention for improving recurrence in patients with CSDH in this particular population. Multicenter rigorous designed prospective randomized trials are still needed to evaluate the role of various drug interventions in improving neurological function or outcome.

Systematic Review Registration: (https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=299491), identifier (CRD 42022299491).

Dehydration Status at Admission Predicts Recurrence in Patients with Traumatic Chronic Subdural Hematoma

Objective: There remains a significant risk of chronic subdural hematoma (CSDH) recurring after treatment. Patient-related predictors and surgical procedures have been investigated in many studies. In contrast, the literature remains scant on reports of the potential impact of dehydration on the admission of affected patients and on the CSDH recurrence rate. Methods: All consecutively admitted patients with CSDH and surgical treatment at the authors’ institution between 2015 and 2019 were retrospectively identified. Dehydration was assessed as a blood urea/creatinine (U/Cr) ratio > 80. The association between dehydration on admission and postoperative complication rates, in-hospital mortality, and recurrence of CSDH, with the need for additional surgical treatment, was further analyzed. Results: A total of 265 patients with CSDH requiring surgery were identified. In 32 patients (12%), further surgery was necessary due to the recurrence of CSDH. It was found that 9 of the 265 patients with CSDH (3%) suffered from dehydration at the time of admission. Multivariate analysis revealed diabetes mellitus (p = 0.02, OR 2.7, 95% CI 1.2−6.5), a preoperative midline shift > 5 mm (p = 0.003, OR 3.3, 95% CI 1.5−7.5) and dehydration on admission (p = 0.002, OR 10.3, 95% CI 2.4−44.1) as significant and independent predictors for the development of CSDH recurrence that requires surgery. Conclusion: the present findings indicate that dehydration on admission appears to be an independent predictor for CSDH recurrence that requires surgery.

Paradigms in chronic subdural hematoma pathophysiology: Current treatments and new directions

ABSTRACT

Chronic subdural hematomas (CSDHs) are an increasingly common pathology encountered in a neurosurgical trauma practice. Although the operative and nonoperative management of CSDH has been studied extensively, the recurrence rate of CSDH remains high, with no significant decrease in recent years. We undertook a detailed assessment of the known pathophysiological mechanisms by which CSDHs recur to improve our ability to treat patients with this disease successfully. In this review of the literature from the PubMed and Scopus databases, we used the search terms "(pathophysiology) AND chronic subdural hematoma [tiab]" to identify pertinent reviews and articles in English. The results demonstrated a complex inflammatory response to subdural blood, which begins with the formation of a collagen neomembrane around the clot itself. Proinflammatory mediators, such as vascular endothelial growth factor, interleukin-6, interleukin-8, tissue necrosis factor α, matrix metalloproteinases, and basic fibroblast growth factor, then contribute to chronic microbleeding by promoting the formation of fragile, leaky blood vessels, and widening of gap junctions of existing vessels. It is evident that the lack of improvement in recurrence rate is due to pathological factors that are not entirely alleviated by simple subdural evacuation. Targeted approaches, such as middle meningeal artery embolization and anti-inflammatory therapies, have become increasingly common and require further prospective analysis to aid in the determination of their efficacy.

Expert consensus on drug treatment of chronic subdural hematoma

Chronic subdural hematoma (CSDH) is a chronic space-occupying lesion formed by blood accumulation between arachnoid and dura mater, which is usually formed in the third week after traumatic brain injury. Surgical treatment is usually the first choice for patients with CSDH having a significant space-occupying effect. Most of the patients showed good results of surgical treatment, but still some patients had a postoperative recurrence (the recurrence rate was up to 33%). Because CSDH is often seen in the elderly, patients are weak and have many basic diseases. The risk of surgical treatment is high; serious complications and even death (the death rate is up to 32%) can often occur. The overall good prognosis rate of patients aged more than 90 years is 24%. The drug treatment can provide a safe and effective treatment for elderly patients who are weak, intolerable to surgery, or failed in surgery. Low-dose and long-term use of atorvastatin (20mg/d) is suggested for continuous treatment for at least 8 weeks, while low-dose and short-term use of dexamethasone can improve the therapeutic effect of atorvastatin on CSDH. Patients should undergo CT or MRI scanning at least one time within 2 weeks after the start of drug treatment.

Middle Meningeal Artery Embolization and the Treatment of a Chronic Subdural Hematoma

Chronic subdural hematoma (cSDH) is a common pathology that typically affects the elderly. It is believed to occur due to injury to the dural border cells, which creates an inflammation/proliferation reaction. Ineffective repair leads to the formation of a new external layer of cells and fragile capillaries, which damage easily and can worsen the condition. Conventionally, asymptomatic cSDH is managed by observation, and symptomatic cases are treated by surgical evacuation. Unfortunately, recurrence rates of the SDH following surgical evacuation can be high. One treatment option for SDH involves embolization of the middle meningeal artery (MMA). The MMA provides blood supply to the dura mater and feeds the membrane capillaries covering the SDH. MMA embolization blocks the blood flow to this system and can promote hematoma resolution. In this paper, we review the existing literature on MMA embolization and discuss the underlying pathophysiology of cSDH.

Effect of angiotensin converting enzyme inhibitors on the development of chronic subdural haematoma

AIMS

Angiotensin converting enzyme inhibitors (ACEI) have been recently discussed in connection with the medical treatment of chronic subdural haematoma (CSDH). They may improve the treatment results. The objective of our study was to evaluate the impact of ACEI on the development of CSDH. The first question was to assess the impact of ACEI on postoperative CSDH healing. The second was to assess the impact of ACEI on the development of CSDH as such.

PATIENTS AND METHODS

The study recruited patients treated surgically for CSDH at our department in the 2013-2018 period. Based on medical records, we retrospectively evaluated the clinical condition of the patients, their history (mainly pharmacological - the use of ACEI) and the course of treatment focussing on the reoccurrence of disease necessitating further therapeutic interventions. For the purpose of evaluating the impact of ACEI on postoperative CSDH healing, the patients were divided into two groups: those using ACEI and those without this medication. The results were compared. We also compared the prevalence of ACEI use in patients with CSDH with the prevalence of ACEI in the comparable population. The difference of the rates allowed us to evaluate the impact of ACEI on the development of CSDH itself.

RESULTS

Of the 217 patients after surgery for CSDH, 79 continued the use of ACEI; the remaining 138 patients did not use this medication. Patients using ACEI after the surgery experienced a recurrence in 24 (30.4%) cases; patients without ACEI in 37 (26.8%) cases. A negligibly higher number of recurrences was recorded in patients with postoperative use of ACEI, but this difference was not statistically significant (P=0.574). Of a total of 230 patients who underwent surgery for CSDH, 81 were using ACEI chronically (35.2%). In the control group of 100 patients, 38 (38.0%) patients used ACEI. The difference was not statistically significant (P=0.629), so it is not possible to assume that ACEIs influence the development of CSDH as such.

CONCLUSION

The initial high hopes for a positive ACEI effect on the healing of CSDH are now waived after the publication of several recent studies. According to our present knowledge, the development of CSDH does not appear to be influenced by ACEI use.

Examining perinatal subdural haematoma as an aetiology of extra-axial hygroma and chronic subdural haematoma

AIM

Benign external hydrocephalus (BEH), hygroma and chronic subdural haematoma are extra-axial fluid collections in infants. MRI studies have shown that almost half of all new-borns have perinatal subdural blood, generally referred to as subdural haematoma (SDH) or perinatal SDH. Epidemiologically there are striking similarities between chronic SDH and BEH in infants.

METHODS

Discussion of pathophysiological mechanisms for BEH and chronic SDH, based on existing literature.

RESULTS

Perinatal SDH is common, and we hypothesise that this condition in some infants develop into extra-axial fluid collections, known as hygroma, BEH or chronic subdural haematoma. The mechanism seems to be an intradural bleeding that creates an obstructive layer preventing normal CSF absorption. The site where the bleeding originates from and those areas enveloped in blood from the primary damaged area are prone to later rebleeds, seen as 'acute on chronic' haematomas. With steady production of CSF and the blockage, increased intracranial pressure drives the accelerated skull growth seen in many of these children.

CONCLUSION

Perinatal SDH hampers CSF absorption, possibly leading to BEH and chronic SDH, with a high risk of false accusations of abuse. Close monitoring of head circumference could prove vital in detecting children with this condition.

A Clinical Study of the Intra-Neuroendoscopic Technique for the Treatment of Subacute-Chronic and Chronic Septal Subdural Hematoma

Objective: The surgical technique, safety, efficacy, and clinical application value of the intra-neuroendoscopic technique (INET) for the treatment of subacute-chronic and chronic septal subdural hematoma was investigated based on the structure and pathological features of the hematoma wall, and the critical factors of hematoma growth and recurrence were determined, in order to provide reference for clinical drug treatment.

Methods: This was non-randomized concurrent control study. A total of 94 patients who met the inclusion criteria were recruited between May 2015 and February 2019 and were divided into the INET treatment group (INET group, 45 cases) and the burr hole drainage (BHD) treatment group (control group, 49 cases). The hematoma fluid components and the morphological structure and pathological characteristics of the hematoma wall were analyzed, and the surgical duration, subdural drainage tube (SDT) placement duration, intracranial infection rate, Bender grade at the 1 month post-operative follow-up and hematoma recurrence rate within the 6 months of post-operative follow-up were compared between the two groups. A multiple logistic regression model was established to analyze the risk factors associated with recurrence within 6 months.

Results: Intraoperative endoscopy showed that the adhesion bands that formed early in the hematoma cavity were strip-like and that those that formed late were lock-column-like. The hematoma cavity was divided into different-sized chambers with by these strips/columns. Pathological sections of cyst wall reveled angiogenesis inside the cyst and mucus-like changes, rupture and hemorrhage in the vascular wall. Obvious inflammatory cell infiltration and fibrous connective tissue hyperplasia were observed in the cyst wall. The osmotic pressure of the hematoma fluid was not significantly different from that of the peripheral venous blood [(296.7 ± 10.3) mOsm/kg vs. (291.5 ± 12.4) mOsm/kg, p = 0.68]. However, the D-dimer contents which reflect the severity of fibrinolysis in the hematoma and the proinflammatory cytokine interleukin 6 (IL-6) were significantly higher in the hematoma fluid than in the peripheral venous blood. The surgery duration for the INET group was significantly longer than that for the control group [(60.4 ± 10.6) min vs. (44.1 ± 9.8) min, p = 0.00], but both the hematoma recurrence rate within 6 months of post-operative follow-up (4.4 vs. 24.5%, p = 0.00) and the SDT placement duration [(2.1 ± 0.6) d vs. (3.9 ± 0.7) d, p = 0.00] for the INET group were both lower than those for the control group. The intracranial infection rate did not differ significantly between the two groups (4.4 vs. 10.2%, p = 0.50). The overall effective rate of the Bender grade at 1 month of follow-up did not differ significantly between the two groups (95.6 vs. 87.8%, p = 0.32), but the proportion of patients who recovered to Bender grade 0 with no symptoms was significantly higher in the INET group than in the control group (86.7 vs. 67.3%, p = 0.03). Multiple logistic regression analysis showed that INET surgery [odds ratio (OR) 3.71, 95% confidence interval (CI) 1.31–9.62, p = 0.02], age of 65 years or younger (OR 1.51, 95% CI 1.05–2.87, p = 0.03) and unilateral subdural hematoma (OR 1.76, 95% CI 1.05–3.41, p = 0.02) were independent factors that reduced the post-operative recurrence rate.

Conclusion: The INET surgical plan based on the structure and pathological features of the subacute-chronic and chronic subdural hematoma wall can reduce the recurrence rate and improve the clinical prognosis.

Trial registration:ClinicalTrials.gov, NCT02515903. Registered 5 August, 2015.

Intracatheter Tissue Plasminogen Activator for Chronic Subdural Hematomas after Failed Bedside Twist Drill Craniostomy: A Retrospective Review

Introduction

Chronic subdural hematomas (cSDH) are common in neurosurgery with various symptoms and significant morbidity and mortality. Treatment varies with procedures including twist-drill (TD) craniostomy, craniotomy, burr hole craniostomy, and craniectomy. Newer treatments including middle meningeal artery embolization are also being explored as no treatment has been determined to be optimal. Due to the lack of consensus treatment, tissue plasminogen activator (tPA) has begun to be investigated to promote drainage and has shown promise in some early studies in reducing recurrence rates. We retrospectively reviewed patients who underwent TD craniostomy and received intracatheter tPA to evaluate the safety and efficacy of this practice.

Methods 

A single-center retrospective review from December 2018 through August 2018 occurred for patients with cSDH 18 years of age or older who underwent a bedside TD craniostomy. Inclusion criteria included all patients who underwent treatment with TD craniostomy for drainage of cSDH during the time period in which tPA protocol was adopted as a possible therapeutic measure at our center. Exclusion criteria included all patients less than age 18 or incarcerated. Patients were stratified into two groups those that received tPA per our center's neurosurgical protocol and those that received drainage alone. Data collected included demographics, hospital/intensive care unit (ICU) length of stay, operative intervention, cSDH thickness throughout stay, length of drainage, and Glasgow Coma Scale (GCS) on arrival and discharge with analysis performed using t-tests.

Results

In all, 20 patients met inclusion: six received tPA at 48 hours per the institutional neurosurgical protocol and 14 did not. The average thickness of cSDH on arrival was significantly larger in the tPA group (26.5 mm vs 14.46 mm, p = 0.0029). Arrival and discharge GCS, average daily drainage, length of stay parameters, and percent change in thickness did not differ between tPA and no tPA groups. The average daily drainage was significantly less prior to the administration of tPA in the tPA group than in the cohort of not receiving tPA (30.71 mL vs 68.99 mL; p = 0.011). Average drainage in patients who received tPA after administration was significantly higher compared to pre-tPA values (131.39 mL vs 30.71 mL; p = 0.046). No patients were readmitted for re-accumulation or required an operating room procedure. There were no adverse outcomes identified through the instillation of tPA.

Conclusion

Intracatheter tPA increased drainage rates in the assessment of pre- and post-tPA values when administered at 48 hours after subdural drain (SDD) placement. Patients who received benefits from tPA tended to have larger subdural hematomas and less drainage prior to the instillation of tPA than patients that benefited from drainage alone. Larger prospective studies should investigate early treatment with tPA to identify if tPA is efficacious for all patients after TD craniostomy and to optimize patient selection with regard to thrombolytic therapy.

Factors influencing the results of surgical therapy of non-acute subdural haematomas

PURPOSE

To identify predictive factors with an impact on the outcome of surgical treatment of non-acute subdural haematomas (NASH).

METHODS

One hundred eleven patients who underwent an evacuation of 132 NASH by means of burr hole or craniotomy from January 2014 to December 2018 were retrospectively analyzed. We evaluated the impact of factors that could possibly predict the result of surgical treatment. The assessment was focused on the impact of factors, such as age, gender, pre-operative clinical symptoms, timing and extent of surgical procedure, intake of anticoagulants and antiplatelet drugs, morphological type, recurrence, side localization or bilateral occurrence of NASH. Patients' functional outcome was quantified using the Glasgow Outcome Score (GOS) with a follow-up period of 3 months.

RESULTS

Morphological type of NASH did not have any significant impact on the final GOS. The risk factors associated with less favorable GOS included preoperative intake of anticoagulants and preoperative finding of phatic disorder, quantitative disorder of consciousness and disorientation. Preoperative intake of antiplatelet drugs or anticoagulants and craniotomy were risk factors for postoperative development of a surgically significant acute extracerebral haematoma. The complications occurred significantly more often after a craniotomy when compared to the burr hole evacuation (p = 0.0163), but the incidence of recurrence of NASH was significantly lower (p = 0.0439).

CONCLUSION

The risk factors for the surgical treatment of NASH included preoperative intake of antithrombotic drugs and evacuation of NASH through craniotomy. Craniotomy resulted in a significantly lower incidence of 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.

Recurrent Chronic Subdural Hematoma: Report of 13 Cases

Chronic subdural hematoma is a frequent type of hemorrhage, which terminates with mortality if not diagnosed and treated early. The aim of this clinical study is to evaluate the patients with unilateral and bilateral recurrent chronic subdural hematoma. The study group consisted of 13 cases with unilateral and bilateral recurrent chronic subdural hematomas who underwent aggressive wide craniotomy, duraectomy, inner and outer membranectomy, dural border coagulation, incision through cortical vein trace and hang up of dural edge, between 2009 - 2016. All of our patients were diagnosed by preoperative Magnetic Resonance Imaging. We evaluated the age, gender, complaints and neurologic signs, localization and thickness of the hematoma. We can estimate that wide craniotomy, duraectomy and membranectomy is a good option in preventing recurrent chronic subdural hematoma and complications.

Management of Subdural Hematomas: Part II. Surgical Management of Subdural Hematomas

PURPOSE OF REVIEW

Management of patients with subdural hematomas starts with Emergency Neurological Life Support guidelines. Patients with acute or chronic subdural hematomas (SDHs) associated with rapidly deteriorating neurologic exam, unilaterally or bilaterally dilated nonreactive pupils, and extensor posturing are considered imminently surgical; likewise, SDHs more than 10 mm in size or those associated with more than 5-mm midline shift are deemed operative.

RECENT FINDINGS

While twist drill craniostomy and placement of subdural evacuating vport system (SEPS) are quick, bedside procedures completed under local anesthesia and appropriate for patients with chronic SDH or patients that cannot tolerate anesthesia, these techniques are not optimal for patients with acute SDH or chronic SDH with septations. Burr hole SDH evacuation under conscious sedation or general anesthesia is an analogous technique; however, it requires basic surgical equipment and operating room staff, with a focus on a closed system with burr hole followed by rapid drain placement to avoid introduction of air into the subdural space, or multiple burr holes with extensive irrigation to reduce pneumocephalus and continue SDH evacuation via drain for several days. Acute SDH associated with significant mass effect and cerebral edema requires aggressive decompression via craniotomy with clot evacuation and frequently a craniectomy. Chronic SDHs that fail conservative management and progress clinically or radiographically are addressed with craniotomy with or without membranectomy. Surgical SDH management is variable depending on its characteristics and etiology, patient's functional status, comorbidities, goals of care, institutional preferences, and availability of specialized surgical equipment and adjunct therapies. Rapid access to surgical suites and trained staff to address surgical hemorrhages in a timely manner, with appropriate post-operative care by a specialized team including neurosurgeons and neurointensivists, is of paramount importance for successful patient outcomes. Here, we review various aspects of surgical SDH management.

Chronic Subdural Hematoma: A Perspective on Subdural Membranes and Dementia

OBJECTIVE

To review the complex pathogenesis of the subdural membrane and the link between head trauma, dementia, and dural lymphatics.

METHODS

A thorough literature search of published English-language articles was performed using PubMed, Ovid, and Cochrane databases.

RESULTS

Chronic subdural hematoma (cSDH) is a common intracranial pathology and a leading cause of reversible dementia. cSDH is projected to affect at least 60,000 new individuals in the United States annually by 2030. This condition can result from mild to moderate head trauma that leads to hemorrhaging in the dura-arachnoid interface. The short-term and long-term effects of cSDH and the subdural membrane on the pathogenesis of dementia and the newly discovered dural lymphatics is a topic of increasing importance.

CONCLUSIONS

Further research into the possible link between traumatic brain injury and cSDH in particular and dural lymphatics and intracranial fluid dynamics is warranted.

Risk Factors of Delayed Surgical Intervention after Conservatively Treated Acute Traumatic Subdural Hematoma

Objective

Acute subdural hematoma (ASDH) is generally considered a condition that should be managed surgically. However, some patients initially receive conservative treatment, a subset of whom require surgical intervention later. This study aimed to evaluate the predictors of delayed surgical intervention in ASDH patients who are initially managed conservatively.

Methods

From January 2007 to December 2015, 842 patients diagnosed with ASDH were treated at our institution. Among them, 158 patients with convexity ASDH were initially treated conservatively. Patients were divided into a delayed surgery group and a conservative group. Demographic characteristics, past medication and medical histories, and radiological and laboratory data were collected by retrospective chart review. Independent risk factors were identified with univariate and multivariate analyses.

Results

Twenty-eight patients (17.7%) underwent delayed surgical intervention. Their mean age was 69.0 years, and 82.1% were male. Hypertension, diabetes mellitus, and heart disease prevalence and use of anti-platelet agents did not significantly differ from the conservative group. However, age (p=0.024), previous cerebral infarction history (p=0.026), increased maximal hematoma thickness (p<0.001), midline shifting (p=0.001) and accompanying subarachnoid hemorrhage (p=0.022) on initial brain computed tomography (CT) scan, low hemoglobin level (p<0.001), high leukocyte count (p=0.004), and low glucose level (p=0.002) were significantly associated with delayed surgical intervention. In multivariate analysis, increased maximal hematoma thickness (odds ratio [OR]=1.279, 95% confidence interval [CI] 1.075–1.521; p=0.006), low hemoglobin level (OR=0.673, 95% CI 0.467–0.970; p=0.034), and high leukocyte count (OR=1.142, 95% CI 1.024–1.272; p=0.017) were independent risk factors for delayed surgical intervention.

Conclusion

Due to the high likelihood of delayed surgical intervention among minimal ASDH patients with a thicker hematoma on initial brain CT, lower hemoglobin level, and higher leukocyte count, these patients should receive more careful observation.

Pathophysiology of chronic subdural haematoma: inflammation, angiogenesis and implications for pharmacotherapy

Chronic subdural haematoma (CSDH) is an encapsulated collection of blood and fluid on the surface of the brain. Historically considered a result of head trauma, recent evidence suggests there are more complex processes involved. Trauma may be absent or very minor and does not explain the progressive, chronic course of the condition. This review focuses on several key processes involved in CSDH development: angiogenesis, fibrinolysis and inflammation. The characteristic membrane surrounding the CSDH has been identified as a source of fluid exudation and haemorrhage. Angiogenic stimuli lead to the creation of fragile blood vessels within membrane walls, whilst fibrinolytic processes prevent clot formation resulting in continued haemorrhage. An abundance of inflammatory cells and markers have been identified within the membranes and subdural fluid and are likely to contribute to propagating an inflammatory response which stimulates ongoing membrane growth and fluid accumulation. Currently, the mainstay of treatment for CSDH is surgical drainage, which has associated risks of recurrence requiring repeat surgery. Understanding of the underlying pathophysiological processes has been applied to developing potential drug treatments. Ongoing research is needed to identify if these therapies are successful in controlling the inflammatory and angiogenic disease processes leading to control and resolution of CSDH.

Spontaneous resolution of large non-traumatic bilateral acute-on-chronic subdural hematoma

Background and importance: Chronic subdural hematomas are a frequently encountered neurosurgical pathology, especially in the elderly. They often require surgical evacuation, but recent studies have shown good results with conservative treatment in selected cases.

Clinical presentation: We report the case of a 72-year old patient that developed large, non-traumatic, bilateral, acute-on-chronic subdural hematoma after repeated abdominal surgery for appendicular carcinoma. He presented an abdominal wound infection and good neurological status (GCS score of 14 points), factors that indicated the delay of surgical intervention. Subsequent clinical and radiological improvement forestalled the operation altogether and he presented complete spontaneous resolution of subdural hematomas at only 5 months after diagnosis.

Conclusion: Although surgical treatment is performed in the majority of chronic subdural hematomas, in clinically and radiologically selected cases, the operation can be avoided. The hematoma can present resolution, either spontaneously or with the help of conservative treatment.

Impact of Time Interval between Trauma Onset and Burr Hole Surgery on Recurrence of Late Subacute or Chronic Subdural Hematoma

Objective

Although subdural hematoma (SDH) is commonly treatable by burr hole surgery in the late subacute or chronic stage, there is no clear consensus regarding appropriate management and exact predictive factors for postoperative recurrence also remain unclear. The aim of this study was to evaluate risk factors associated with recurrence of SDH that requires burr hole surgery in the late subacute or chronic stage. We also identified the appropriate timing of surgery for reducing the recurrence.

Methods

We retrospectively reviewed 274 patients with SDH in the late subacute or chronic stage treated with burr hole surgery in our hospital between January 2007 and December 2014. Excluding patients with acute intracranial complications or unknown time of trauma onset left 216 patients included in the study.

Results

Of 216 patients with SDH in the late subacute or chronic stage, recurrence was observed in 36 patients (16.7%). The timing of the operation in patients with late subacute stage (15–28 days) resulted in a significant decrease in recurrence (RR, 0.33; 95% CI, 0.17–0.65; p=0.001) compared to chronic stage (>28 days). Otherwise, no significant risk factors were associated with recurrences including comorbidities and surgical details.

Conclusion

The results indicated that time from trauma onset to burr hole surgery may be important for decreasing the risk of recurrence. Therefore, unless patients can be treated conservatively without surgery, prompt surgical management is recommended in patients diagnosed as having late subacute or chronic subdural hematoma treatable by burr hole surgery, even when neurological deficits are unclear.

Intraoperative Ultrasonography during Drainage for Chronic Subdural Hematomas: A Technique to Release Isolated Deep-seated Hematomas--Technical Note

After the drainage of chronic subdural hematomas (CSDHs), residual isolated deep-seated hematomas (IDHs) may recur. We introduce intraoperative ultrasonography to detect and remove such IDHs. Intraoperative ultrasonography is performed with fine transducers introduced via burr holes. Images obtained before dural opening show the CSDHs, hyper- and/or hypoechoic content, and mono- or multilayers. Images are also acquired after irrigation of the hematoma under the dura. Floating hyperechoic spots (cavitations) on the brain cortex created by irrigation confirm the release of all hematoma layers; areas without spots represent IDHs. Their overlying thin membranes are fenestrated with a dural hook for irrigation. Ultrasonographs were evaluated in 43 CSDHs (37 patients); 9 (21%) required IDH fenestration. On computed tomography scans, 17 were homogeneous-, 6 were laminar-, 16 were separated-, and 4 were trabecular type lesions. Of these, 2 (11.8%), 3 (50%), 4 (25%), and 0, respectively, manifested IDHs requiring fenestration. There were no technique-related complications. Patients subjected to IDH fenestration had lower recurrence rates (11.1% vs. 50%, p = 0.095) and required significantly less time for brain re-expansion (mean 3.78 ± 1.62 vs. 18 ± 5.54 weeks, p = 0.0009) than did 6 patients whose IDHs remained after 48 conventional irrigation and drainage procedures. Intraoperative ultrasonography in patients with CSDHs facilitates the safe release of hidden IDHs. It can be expected to reduce the risk of postoperative hematoma recurrence and to shorten the brain re-expansion time.

Risk factors of delayed surgical evacuation for initially nonoperative acute subdural hematomas following mild head injury

BACKGROUND

Although the majority of patients with minimal acute subdural hematomas (aSDHs) can be managed conservatively, some require delayed aSDH evacuation due to hematoma enlargement. This study was designed to determine the risk factors associated with delayed hematoma enlargement leading to surgery in patients with aSDHs who did not initially require surgical intervention.

METHODS

From 2002 to 2012, 98 patients were treated for nonoperative aSDHs following mild head injury (Glasgow Coma Scale scores of 13-15). The outcome variables were radiographic evidence of SDH enlargement on serially obtained computed tomography (CT) images and later surgical evacuation. Univariate and multivariate analyses were applied to both the demographic and initial radiographic features to identify risk factors for SDH progression and surgery.

RESULTS

Overall, 64 patients (65 %) revealed minimal SDH or spontaneous hematoma resolution (conservative group) with conservative management at their last follow-up CT scan. The remaining 34 patients (35 %) received delayed hematoma evacuation (delayed surgery group) a median of 17 days after the head trauma. There were no significant differences between the two groups for baseline characteristics, including age, injury type, degree of brain atrophy, prior history of antithrombotic drugs, and coagulopathy. The presence of cerebral contusions and subarachnoid hemorrhages was more common in the conservative group (p = 0.003 and p = 0.003, respectively). On multivariate analysis, hematoma volume (p = 0.01, odds ratio [OR] = 1.094, 95 % confidence interval [CI] = 1.021-1.173) and degree of midline shift (p = 0.01, OR = 1.433, 95 % CI = 1.088-1.888) on the initial CT scan were independently associated with delayed hematoma evacuation.

CONCLUSIONS

A critical proportion of patients with minimal aSDHs occurring after mild head injury can progress over several weeks and require hematoma evacuation. Especially patients with a large initial SDH volume and accompanying midline shift require careful monitoring of hematoma progression.

Clinical Analysis of Risk Factors for Recurrence in Patients with Chronic Subdural Hematoma Undergoing Burr Hole Trephination

OBJECTIVE

Chronic subdural hematoma (CSDH) is one of the most common types of intra-cranial hemorrhages usually associated with trauma. Surgical treatment is the treatment of choice and burr hole trephination (BHT) is widely performed. The recurrence rate in the patients with CSDH is 3.7-30%. This study investigated the risk factors associated with the recurrence of patients with CSDH who underwent BHT.

METHODS

One hundred twenty-five patients with CSDH underwent BHT. Eight of 125 patients (6.4%) underwent reoperation for recurrent CSDH. We retrospectively analyzed demographic, clinical and radiological findings, catheter tip location and drainage duration as the risk factors for the recurrence of CSDH.

RESULTS

Recurrence of CSDH in the high- or mixed-density groups was significantly higher than those in the low- or iso-density groups (p<0.001). Placement of catheter tip at the temporoparietal area was associated with a significantly higher recurrence rate of CSDH than placement at the frontal area (p=0.006) and the brain re-expansion rate (BRR) was much lower than placement at the frontal area (p<0.001).

CONCLUSION

The operation may be delayed in high- and mixed-density groups, unless severe symptoms or signs are present. In addition, placing the catheter tip at the frontal area helps to reduce the incidence of postoperative recurrence of CSDH and to increase the BRR.

Effect of inner membrane tearing in the treatment of adult chronic subdural hematoma: a comparative study

The postoperative results of chronic subdural hematoma (CSDH) procedures using catheterization and tearing of inner membrane (CTIM) technique have not previously been discussed in the literature. This article compares the effects of CTIM technique on brain re-expansion and re-accumulation with cases operated on with a burr-hole craniotomy and outer membrane incision (BCOMI) technique. The study involved operations on 144 patients (Group 1) using the CTIM technique and 108 patients (Group 2) using the BCOMI technique. In the operations using the CTIM technique in Group 1, the mean effusion measured in the subdural space (SDS) was 10.0 ± 0.2 mm, and for Group 2, 14.3 ± 0.6 mm in the postoperative period on the first and third days and this difference was found to be significant (p < 0.05). The means were 6.6 ± 0.2 mm for Group 1 and 10.3 ± 0.5 mm for Group 2 on the seventh day (p < 0.05). Recurrence rate was 8.3% in Group 2 and 0 in Group 1. This difference was statistically significant (p = 0001). The length of hospital stay was 7.0 ± 0.1 days for the Group 1 and 8.8 ± 0.2 days for Group 2 and this difference was significant (p < 0.05). These results indicate that the CTIM technique is preferable because it results in earlier re-expansion, lower recurrence, less subdural effusion and pneumocephalus, and shorter hospital stays.

Measurement of inflammatory cytokines and thrombomodulin in chronic subdural hematoma

Inflammation and the coagulation system may influence the genesis of chronic subdural hematoma (CSDH). The appearance of CSDH on computed tomography (CT) varies with the stage of the hematoma. This study investigated the pathogenesis and the recurrence of CSDH by comparing cytokine levels with the CT features of CSDH in 26 patients with 34 CSDHs who underwent single burr-hole surgery at our hospital between October 2004 and November 2006. The hematoma components removed during the procedure were examined, and the hematoma serum levels of cytokines measured such as thrombomodulin (TM), interleukin-6 (IL-6), tumor necrosis factor-α (TNFα), and interleukin-10 (IL-10). Using CT, mixed density hematomas were distinguished from other homogeneous hematomas, and found that the TM level was significantly higher in mixed density hematomas than in homogeneous hematomas (p = 0.043). Mixed density hematomas were classified into three subtypes (laminar, separated, and trabecular hematomas). The TM level was significantly higher in laminar and separated hematomas than in other hematomas (p = 0.01). The levels of IL-6, TNFα, and IL-10 were extremely high, but showed no significant differences in relation to the CT features. Mixed density hematomas had high recurrence rate, as reported previously, and TM level was high in mixed density hematomas such as laminar and separated mixed density hematomas. The present findings suggest that the types of CSDH associated with high TM levels tend to have higher recurrence rate.

Multiple Densities of the Chronic Subdural Hematoma in CT Scans

Objective

Density of the chronic subdural hematoma (cSDH) is variable. It often appears to be mixed density. Multiple densities of cSDH may result from multiple episodes of trauma. We investigated the frequency of mixed density and the causes of head injuries representing each density.

Methods

We could collect 242 cases of chronic SDH. The cSDHs were classified into four groups; hypodensity, homogeneous isodensity, layered type, and mixed type on the basis of CT scans.

Results

The density of cSDH was isodense in 115 patients, hypodense in 31 patients, mixed in 79 cases, and layered in 17 cases. The cSDH was on the left side in 115 patients, on the right side in 70 patients, and bilateral in 40 patients. The history of trauma was identifiable in 122 patients. The etiology could be identified in 67.7% of the hypodense hematomas, while it was obscure in 59.5% of the mixed hematomas.

Conclusion

Mixed density of cSDH results from multiple episodes of trauma, usually in the aged. It is hard to remember all the trivial traumas for the patients with the mixed density cSDHs. Although there were membranes within the mixed density hematomas, burr-holes were usually enough to drain the hematomas.

Clinical characteristics and risk factors of chronic subdural haematoma associated with clipping of unruptured cerebral aneurysms

Chronic subdural haematoma (CSDH) is an uncommon but potentially serious complication of clipping unruptured cerebral aneurysms. We conducted a study to identify the patients who are at risk of developing postoperative CSDH. The data from 713 consecutive patients who underwent clipping of unruptured anterior circulation aneurysms were reviewed, and risk factors correlated with CSDH were identified by multivariate regression analysis of demographic variables. Fifteen patients (2.1%) developed CSDH after the surgery. Advanced age (odds ratio [OR] 1.151, 95% confidence interval [CI] 1.051-1.261) and male gender (OR 3.167, 95% CI 1.028-9.751) were correlated with CSDH. Subsequently, all 713 patients were quadrichotomized on the basis of gender and age, with 70 years as the cut-off value for age. The frequency of CSDH in men <70 years of age was 1.3% and that in men ≥70 years of age was 15.1%, with risk of CSDH was significantly higher in the older men (OR 13.39; 95% CI: 3.42-52.44). The frequency of CSDH in women <70 years of age was 0.6% and that in women ≥70 years of age was 3.7%. As in men, the risk of CSDH was significantly higher in the older women (OR 6.69, 95% CI 1.10-40.73). The interval between the aneurysm clipping and CSDH development was 0.5-6 months, suggesting that clinical observation should be continued up to 6 months after surgery. Although prognosis for patients with a postoperative CSDH complication is generally favourable, the risk of CSDH should be taken into account when considering elective clipping of unruptured aneurysms in patients ≥70 years of age.

The level of circulating endothelial progenitor cells may be associated with the occurrence and recurrence of chronic subdural hematoma

OBJECTIVES

The onset of chronic subdural hematoma may be associated with direct or indirect minor injuries to the head or a poorly repaired vascular injury. Endothelial progenitor cells happen to be one of the key factors involved in hemostasis and vascular repair. This study was designed to observe the levels of endothelial progenitor cells, white blood cells, platelets, and other indicators in the peripheral blood of patients diagnosed with chronic subdural hematoma to determine the possible relationship between the endothelial progenitor cells and the occurrence, development, and outcomes of chronic subdural hematoma.

METHOD

We enrolled 30 patients with diagnosed chronic subdural hematoma by computer tomography scanning and operating procedure at Tianjin Medical University General Hospital from July 2009 to July 2011. Meanwhile, we collected 30 cases of peripheral blood samples from healthy volunteers over the age of 50. Approximately 2 ml of blood was taken from veins of the elbow to test the peripheral blood routine and coagulation function. The content of endothelial progenitor cells in peripheral blood mononuclear cells was determined by flow cytometry.

RESULTS

The level of endothelial progenitor cells in peripheral blood was significantly lower in preoperational patients with chronic subdural hematomas than in controls. There were no significant differences between the two groups regarding the blood routine and coagulation function. However, the levels of circulating endothelial progenitor cells were significantly different between the recurrent group and the non-recurrent group.

CONCLUSIONS

The level of circulating endothelial progenitor cells in chronic subdural hematoma patients was significantly lower than the level in healthy controls. Meanwhile, the level of endothelial progenitor cells in recurrent patients was significantly lower than the level in patients without recurrence. Endothelial progenitor cells may be related to the occurrence and recurrence of chronic subdural hematoma.

Encapsulated acute subdural hematoma mimicking acute epidural hematoma on computed tomography

An 87-year-old woman presented with an atypical case of acute subdural hematoma (ASDH) manifesting as disturbance of consciousness and left hemiparesis. Computed tomography revealed a high density lentiform lesion in the right convexity, which was thought to be acute epidural hematoma preoperatively. Emergent decompressive craniotomy revealed an encapsulated solid fresh clot in the subdural space and a bleeding small cortical artery under the clot. The arachnoid membrane and the brain parenchyma were intact, and no other abnormal feature such as aneurysm or arteriovenous malformation was observed. The encapsulated ASDH was removed en bloc and the patient fully recovered. Histological examination confirmed that both the outer thicker and the inner membrane were fibrinous single structures without vasculature. The red blood cells constituting the clot in the capsule maintained their cell structure. The reported pathological mechanisms of lentiform ASDH are adhesion of the arachnoid membrane and the dura mater or intracapsular bleeding from sinusoidal vessels in the outer membrane of the chronic subdural hematoma. However, in our case, the arachnoid membrane had not adhered to the dura mater and the capsule was a fibrinous single structural membrane without vasculature, which probably resulted from a previous hematoma due to initial bleeding from the cortical artery. The possible mechanism in our case was that the re-bleeding dissected and flowed into the fibrinous single structural membrane, resulting in formation of the lentiform ASDH.

Recurrence-free chronic subdural hematomas: a retrospective analysis of the instillation of tissue plasminogen activator in addition to twist drill or burr hole drainage in the treatment of chronic subdural hematomas

OBJECTIVE

To evaluate whether increasing the volume drained from chronic subdural hematomas (SDHs) via either twist drill drainage (TDD) or burr hole drainage (BHD) followed by instillation of tissue plasminogen activator (tPA) is more efficacious than simple drainage alone.

METHODS

Patients admitted over the course of 42 months (2007-2010) to a single institution for treatment of chronic SDH were retrospectively evaluated.

RESULTS

There were 139 patients treated for chronic SDH; 54 patients were treated with BHD alone, 3 were treated with tPA after BHD, 85 were treated with TDD alone, and 12 were treated with tPA after TDD. Follow-up examinations were performed 1 month after treatment in 13 of 15 patients treated with tPA and 93 of 124 patients treated without tPA. Patients treated with tPA had a significantly lower rate of recurrence than patients treated without tPA (P=0.041). Patients treated with BHD had a recurrence rate of 11.8%, whereas patients treated with BHD and tPA had 0% recurrence. Patients treated with TDD had a recurrence rate of 30%, whereas patients treated with TDD and tPA had 0% recurrence. Without tPA, BHD was found to be a significantly better treatment than TDD (P=0.016). Mean drainage for TDD with tPA was 427.33 mL. There were no complications related to the administration of tPA.

CONCLUSIONS

This study adds another therapeutic option for patients with chronic SDH requiring treatment. In this retrospective study, the addition of tPA increased the volume of hematoma drained and significantly reduced the incidence of recurrence requiring further intervention regardless of cranial access route. No complications occurred related directly or indirectly to the administration of tPA. Further study of this technique is warranted.