Organized Chronic Subdural Hematomas Treated by Large Craniotomy with Extended Membranectomy as the Initial Treatment

Incision of the Internal Membrane Under an Endoscope for Advanced Organized Chronic Subdural Hematoma: A Case Report

Craniotomy with membranectomy is recommended for advanced organized chronic subdural hematomas (CSDH) that do not resolve with burr-hole irrigation and drainage. Nevertheless, the procedure remains controversial because of its potential complications, which include postoperative acute subdural hematomas and epileptic seizures. At present, for advanced organized CSDH, there is no clear consensus on whether complete membrane removal or incisions are the optimal management. We have obtained good results by performing a small craniotomy and making incisions in the thick, organized inner membrane with a sharp blade, without dissecting the inner membrane. Here, we report a case of organized CSDH that was successfully resolved by the same procedure performed with an endoscope through the burr-hole. An 81-year-old man was referred to our hospital with twice-recurrent CSDH after two burr-hole surgeries, accompanied by persistent left-sided motor weakness. A magnetic resonance imaging revealed an organized inner membrane, so an endoscopic incision of the inner membrane was performed through the previously opened burr-hole. After the clots in the hematoma cavity were cleanly removed, incisions were made randomly in the inner membrane using a sharp blade, with care not to damage the cortex, until pulsation of the brain tissue was observed endoscopically. A follow-up head computed tomography scan on the third postoperative day confirmed brain expansion. The patient recovered completely from the left-sided paralysis and was discharged home on the 20th postoperative day. In an advanced organized CSDH, the brain will not expand without treatment of the inner membrane, and CSDH will invariably recur. Detaching the hard inner membrane is not necessary, and once multiple incisions are made with a scalpel and the brain pulsation is confirmed, expansion can be expected after drainage of the hematoma cavity over multiple days. Several reports of successful treatment for organized CSDH have been reported, but absolute treatment has not yet been established. Incision of the inner membrane in endoscopic burr-hole surgery is a viable treatment option, with the need for large-scale pragmatic studies to prove safety and efficacy.

Organized chronic subdural hematoma with cognitive impairment: A case report and literature review

RATIONALE

Organic chronic subdural hematoma is extremely rare in clinical practice, with unclear etiology and pathogenesis. Its clinical manifestations and treatment approaches are diverse, making diagnosis challenging and prone to misdiagnosis or mistreatment, adversely affecting patient care and quality of life.

PATIENT CONCERNS

The 58-year-old male patient exhibited cognitive impairment, characterized by memory deficits and delayed responses, over 1 month in the absence of notable medical comorbidities.

DIAGNOSES

Initial neurological assessment upon admission showed cognitive deficits, with a Mini-Mental State Examination score of 18 and a Montreal Cognitive Assessment Scale score of 22. Imaging with a computed tomography scan revealed a subdural mass with low density. The preoperative diagnosis indicated a chronic subdural hematoma (may combined with intracranial hypertension) located at the apex of the right frontotemporal region, potentially with septation.

INTERVENTIONS

A bone flap craniotomy was proceeded under microscopic guidance for lesion resection. Postoperatively, the patient received targeted interventions, including fluid replacement, to promote brain tissue recovery and functional rehabilitation.

OUTCOMES

After treatment, the patient demonstrated improvement and was discharged from the hospital. Over the 1-year postoperative period, he reported mild recent memory decline but remained asymptomatic, continued his usual activities, and demonstrated improved cognitive function, as evidenced by Mini-Mental State Examination and Montreal Cognitive Assessment Scale scores of 28 and 29, respectively, along with normal muscle strength in all limbs.

LESSONS

Patients with mild or no significant symptoms, such as headaches and dizziness, are advised to undergo regular imaging follow-ups. Surgical intervention is recommended for patients presenting with intracranial hypertension and neurological impairment, with bone flap craniotomy and lesion resection under microscopic guidance being the preferred approach. It is imperative to conduct regular postoperative monitoring to promptly detect potential complications, such as hematoma recurrence.

Role of Sulcal Hyperintensity and Web/Net Appearance on MRI in Patients With Chronic Subdural Hematoma Presenting With Transient Neurological Deficits

BACKGROUND AND OBJECTIVES

Transient neurological deficits (TNDs) in patients with chronic subdural hematoma (CSDH), such as fluctuating aphasia, hemiparesis, or sensory disturbances, present diagnostic and treatment challenges as their pathophysiology remains unclear. The aim of this study was to investigate the association between specific MRI findings and TNDs in patients with CSDH and explored their relationship through intraoperative observation.

METHODS

We retrospectively evaluated 72 patients with CSDH who underwent preoperative MRI among 251 CSDH patients treated from January 2020 to December 2023. Sulcal hyperintensity (SHI) on fluid-attenuated inversion recovery images and web/net appearance (W/N) on T2*-weighted images were assessed and their association with TNDs was analyzed. Flexible neuroendoscopic surgery (FNS) was performed on 8 patients with TNDs exhibiting these MRI findings, allowing intraoperative observation of intrahematoma conditions. Histopathological examination was performed on hematoma samples.

RESULTS

Thirteen patients (5.2%) presented with preoperative TNDs. Diffuse SHI and W/N were strongly associated with preoperative TNDs (odds ratio = 150.0, P < .001). FNS revealed organized hematomas with inflammatory changes corresponding to the SHI and W/N seen on MRI. Patients who underwent FNS experienced complete resolution of TNDs postprocedure, with diffuse SHI disappearing by one month. No recurrence was observed at a mean follow-up of 5.9 months.

CONCLUSION

This study provided the first evidence that the combination of diffuse SHI and W/N on MRI strongly correlates with TNDs in patients with CSDH, serving as valuable diagnostic indicators. These findings will aid in guiding surgical approach selection and facilitate more personalized treatment strategies for patients with CSDH presenting with TNDs.

Diffusion-weighted imaging findings predictive of postoperative recurrence of chronic subdural hematoma

OBJECTIVES

To identify the brain magnetic resonance imaging (MRI) findings associated with the postoperative recurrence of chronic subdural hematoma (CSDH).

METHODS

We examined 1099 consecutive patients admitted to our hospital with CSDH between 2005 and 2014. Of those, 1021 who underwent surgery for CSDH and were followed-up for >3 months after surgery were included. Preoperative brain MRI findings were classified as homogeneous, laminar, separate, or trabecular, according to the nature of the hematoma. Postoperative recurrence was defined in patients who required reoperation for ipsilateral hematoma growth within three months of surgery. The clinical and radiological factors associated with postoperative recurrence were evaluated using univariate and multivariate analyses.

RESULTS

Of the 1021 CSDH patients with CSDH who underwent surgery, 91 (8.9%) experienced postoperative recurrence. Postoperative recurrence was significantly associated with male sex (p = 0.0004) and hematoma volume (p < 0.0001). Additionally, isotype or separate types of hematoma on computed tomography (CT) (p < 0.0001) and laminar/separate types of hematoma types on MRI (p = 0.0008) were significant. Multivariate analysis revealed odds ratios of 2.50 (95% CI, 1.45-4.61; p = 0.0007) for male sex and 3.05 (95% CI, 1.95-4.87; p < 0.0001) for iso/separate hematoma types in CT. Conversely, among the patients who underwent MRI, multivariate analysis revealed odds ratios of 4.33 (95% CI, 1.20-27.92; p = 0.001) for male sex and 4.88 (95% CI, 1.90-14.18; p = 0.023) for laminar/separate hematoma types.

CONCLUSION

While distinguishing the nature of hematomas is challenging with brain CT examination, detailed laminar/trabecular differentiation using MRI images may predict postoperative recurrence.

Preoperative middle meningeal artery embolization in the treatment of organized chronic subdural hematoma

Organized chronic subdural hematoma is a rare form of chronic subdural hematoma. The optimal treatment method is still controversial. Preoperative middle meningeal artery embolization and craniotomy are effective methods for chronic subdural hematoma. However, there are not many reports investigating the effectiveness of these methods in treating organized chronic subdural hematoma. We report the case of a 61-year-old male patient who had a twist-drill craniostomy to treat a left hemisphere subdural hematoma. After surgery, there was a recurrence on the same side in the form of an organized subdural hematoma. The patient received preoperative left middle meningeal artery embolization. After 3 months of follow-up, a small portion of the hematoma remained, causing pressure and slightly shifting the midline to the right by 6.5 mm, and the patient no longer had clinical symptoms.

An Algorithm for Treatment of Symptomatic Chronic Subdural Hematomas

INTRODUCTION

Although chronic subdural hematoma (CSDH) is a common neurosurgical disease, there is a lack of algorithms for the treatment of asymptomatic and symptomatic CSDH. The purpose of this article is to describe an algorithm developed using our institutional experience for the treatment of symptomatic CSDH that aims to decrease symptoms and/or hematoma size or to completely resolve both. Our algorithm for treatment of symptomatic CSDH includes subdural drain (SDD) placement via twist-drill craniostomy (TDC) as the first-line treatment, followed by supplemental tissue plasminogen activator (tPA) as second-line treatment, with possible middle meningeal artery embolization (MMAE), followed by craniotomy as the last therapeutic option. This study investigated the efficacy of our institution's algorithm in treating symptomatic CSDH.

METHODS

A retrospective study was conducted from 2019 to 2023 identifying patients with CSDH treated with TDC. Electronic medical records were used to gather patient demographics, clinical presentation, radiographic findings, treatment modalities, and clinical outcomes.

RESULTS

There were a total of 109 patients with 128 SDD placements. All 109 patients underwent TDC; among them, 37 patients received tPA instillation with three patients requiring craniotomy. Factors including age, gender, race, mechanism of injury, blood thinner usage, Glasgow Coma Scale (GCS), neurologic exam, thickness of CSDH, and midline shift were comparable for all patients regardless of treatment received. The mean number of neomembranes was higher in patients who eventually required craniotomy (4.5) compared to those treated with TDC only (1.8) and TDC+tPA (2.1) (p=0.0035). There was a greater mean hematoma drainage in patients who received tPA instillation without craniotomy (586.7 mL) than those treated with TDC only (293.0 mL) (p<0.0001). Clinical improvement was found in 52/72 patients (72.2%) treated with TDC only, 23/34 patients (67.6%) treated with TDC+tPA only, and 0/3 patients (0.0%) treated with TDC+tPA+craniotomy. Radiographic improvement in mean thickness of CSDH and midline shift, respectively, was found in patients treated with TDC only (p<0.0001; p<0.0001) and TDC+tPA (p<0.0001; p<0.0001) but not in TDC+tPA+craniotomy (p=0.1494; p=0.0762). There were also fewer neomembranes after TDC+tPA treatment only (2.1 vs. 0.5, p<0.0001). Seven patients were readmitted that did not follow the algorithm and only patients treated following the algorithm showed clinical and radiographic improvement.

CONCLUSIONS

Using our institutional algorithm, our study demonstrates successful clinical outcomes in treating symptomatic CSDH and recurrent CSDH with minimally invasive therapeutic interventions including SDD via TDC and tPA, thereby minimizing the utilization of more invasive interventions including craniotomy.

Tension pneumocephalus as a complication of surgical evacuation of chronic subdural hematoma: case report and literature review

The management of symptomatic chronic subdural hematoma (CSDH) is surgical evacuation and prognosis in most cases is good. Tension pneumocephalus is the presence of air under pressure in the intracranial cavity. A case of tension pneumocephalus developing as a complication of burr hole evacuation of CSDH is illustrated. In this case, tension pneumocephalus was managed by reopening the wound and saline irrigation with a subdural drain placement. Considering this case report and after a careful review of the literature, the physiopathology, diagnosis, and treatment of this complication are highlighted in the article.

Comparison of different surgical techniques for chronic subdural hematoma: a network meta-analysis

Background

Chronic subdural hematoma (CSDH) is a neurosurgical condition with high prevalence. Many surgical approaches are recommended for treating CSDH, but there needs to be a consensus on the optimal technique. This network meta-analysis (NMA) compared the efficacy and safety of different surgical treatments for CSDH.

Methods

Electronic databases, including PubMed, Embase, and the Cochrane Library, were searched for relevant studies up to February 2023. An NMA was performed to compare the outcomes of patients with CSDH treated by single-hole or double-hole craniotomy (SBHC and DBHC, respectively), twist-drill craniotomy (TDC), mini-craniotomy, and craniotomy. The NMA protocol was registered at INPLASY (registration no. 202320114).

Results

The NMA included 38 studies with 7,337 patients. For efficacy outcomes, DBHC showed the highest surface under the cumulative ranking area (SUCRA) values for recurrence (96.3%) and reoperation (87.4%) rates. DBHC differed significantly from mini-craniotomy in recurrence rate (odds ratio [OR] = 0.58, 95% confidence interval [CI]: 0.35, 0.97) and from SBHC (OR = 0.48, 95% CI: 0.25, 0.91) and TDC (OR = 0.40, 95% CI: 0.20, 0.82) in reoperation rate. For operative time, TDC was superior to SBHC (mean difference [MD] = -2.32, 95% CI: -3.78 to -0.86), DBHC (MD = -3.61, 95% CI: -5.55, -1.67), and mini-craniotomy (MD = -3.39, 95% CI: -5.70, -1.08). Patients treated by TDC had a shorter hospital stay than those treated by SBHC (MD = -0.82, 95% CI: -1.51, -0.12). For safety outcomes, there were no significant differences between groups in mortality and complication rates; however, mini-craniotomy (79.8%) and TDC (78.1%) had the highest SUCRAs.

Conclusion

DBHC may be the most effective surgical treatment for CSDH based on the low recurrence and reoperation rates, although all examined techniques were relatively safe.

Systematic review registration

https://inplasy.com/inplasy-2023-2-0114/.

Homogeneous Chronic Subdural Hematoma with Diverse Recurrent Possibilities

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

Middle meningeal artery embolization before craniotomy for infected organizing chronic subdural hematoma: A case report and review of the literature

Background:

Organizing chronic subdural hematoma (OSDH) is intractable and its radical treatment remains controversial. Middle meningeal artery embolization has emerged as an adjunctive treatment to craniotomy for OSDH.

Case Description:

The patient is an 86-year-old man. He had been taking warfarin for atrial fibrillation and was referred to the department for the treatment of bilateral chronic subdural hematoma (CSDH), which was found on head computed tomography after a fall. Bilateral burr hole drainages were performed, but his hematomas were organized, so the hematomas could not be drained sufficiently. The patient was discharged from the hospital without any neurological symptoms. Two months later, the patient presented with persistent fever and headache and had recurrent bilateral CSDHs. The hematoma on the right side was larger. Based on the initial intraoperative findings, OSDH was suspected, and craniotomy was performed on the right hematoma. Propionibacterium acnes were detected in the hematoma culture, and antimicrobial therapy was started postoperatively. Since the right hematoma recurred on the 7^th postoperative day, bilateral middle meningeal artery (MMA) embolization with 20% n-butyl-2-cyanoacrylate was performed, followed by craniotomy for the left hematoma and drainage for the right recurrent hematoma. Antimicrobials were administered for 2 weeks after the last operations. Six months after the operations, both bilateral hematomas had almost disappeared.

Conclusion:

Craniotomy is effective for the treatment of infected OSDH, and MMA embolization is useful to reduce the risk of bleeding complications in the perioperative period, and may also reduce the recurrence of CSDH.

Organized Chronic Subdural Hematoma Treated with Middle Meningeal Artery Embolization and Small Craniotomy: Two Case Reports

The most preferred treatment for organized chronic subdural hematoma (OSDH) remains controversial. Although a large craniotomy has been reported to be necessary and effective for the treatment of an OSDH, a craniotomy is associated with postoperative hemorrhagic complications and recurrence. Although middle meningeal artery (MMA) embolization has been reported to be effective for a refractory chronic subdural hematoma (CSDH), its efficacy for an OSDH remains unclear. We report two cases of OSDH treated with MMA embolization followed by hematoma removal via a small craniotomy under local anesthesia with good progress. Case 1: A 71-year-old man underwent a single burr hole irrigation for a CSDH, which failed due to a solid hematoma. He underwent a small craniotomy under local anesthesia after an MMA embolization. During the craniotomy, a small hemorrhage from the hematoma and its outer membrane was observed. Postoperatively, the symptoms disappeared immediately, and the hematoma did not recur. Case 2: A 77-year-old man underwent a burr hole irrigation, but the hematoma was not evacuated because of an OSDH, and he remained in motor aphasia. After an MMA embolization, a craniotomy was performed under local anesthesia. Intraoperative hemorrhage was minimal, and after the craniotomy, his neurological symptoms improved without any recurrence. MMA embolization and hematoma removal with a small craniotomy could be a treatment option for an OSDH.

Calcified or Ossified Chronic Subdural Hematoma: A Systematic Review of 114 Cases Reported During Last Century with a Demonstrative Case Report

OBJECTIVE

Calcified or ossified chronic subdural hematoma (CSDH), characterized by slowly progressing neurologic symptoms, is a rarely seen entity that may remain asymptomatic for many years. Management of CSDH has improved dramatically in recent years as a result of advances in diagnostic tools, but there is still some controversy regarding the optimal treatment strategy.

METHODS

In this systematic review, PRISMA guidelines were followed to query existing online databases between January 1930 and December 2018. We found a total of 88 articles containing 114 cases of calcified or ossified CSDH, comprising 83 patients operated on and 31 not operated on.

RESULTS

In this study, there were 78 males and 29 females (7 with unreported gender) from 25 countries, ages ranging from 4 months to 86 years (mean, 33.7 years), with CSDH caused by head trauma in 33.3%, shunting for hydrocephalus in 27.2%, or after cranial surgery in 4.4%. The duration of symptoms ranged from acute onset to 20 years, with a mean of 24.1 months. Imaging techniques such as radiography, computed tomography, and magnetic resonance imaging were used, with pathologic confirmation of CSDH and complete recovery in 56.4% of patients.

CONCLUSIONS

Incidence of calcified or ossified CSDH is high in certain countries, including the United States, Japan, and Turkey, with a steady increase in recent years. The therapy of choice is surgery in these patients and it should be considered in the differential diagnosis at presentation because of its infrequency and variable clinical manifestation, after shunting in children or head trauma in adults.

Intraoperative point-of-care assessment of an inflammatory biomarker in chronic subdural hematomas: Technical note

OBJECTIVE

Inflammatory processes have been associated with the development and recurrence of chronic subdural hematomas (cSDH). Elevated levels of presepsin, a truncated N-terminal fragment of soluble CD14, occur in various inflammatory conditions of bacterial and non-bacterial origin. Here we report on our initial experiences with the intraoperative point-of-care (POC) assessment of presepsin in patients treated for cSDH.

PATIENTS AND METHODS

The POC analyser Pathfast® was used in 21 patients treated for cSDH at our institution. Prior to surgery, levels of C-reactive protein (CRP) and white blood cells (WBC) were assessed. After burr hole trephination and dura incision, samples of subdural fluid and whole blood were collected and immediately assessed with the POC analyser. Values of presepin were compared between samples of the subdural compartment and whole blood.

RESULTS

Presepsin levels were assessed within 13 min in all patients and no technical difficulties occurred. Compared to the reported normal range values of presepsin (55-184 pg/mL), mean levels of presepsin in samples of the subdural compartiment was increased more than 5-fold (821 ± 110.1 pg/mL). Furthermore, mean presepsin values in samples of the subdural compartiment were significantly higher than in samples of whole blood (154.8 ± 19.2 pg/mL; p < 0.0001).

CONCLUSION

POC assessment of the inflammatory biomarker presepsin is feasible within minutes during surgical treatment of cSDH. Corresponding to previous studies, presepsin levels were highly elevated in the subdural fluid, indicating processes of inflammation. Whether results of intraoperative POC assessment of inflammatory biomarkers is associated with outcome parameters in patients treated for cSDH has to be addressed in further studies. In our view, there is a role for this promising technique in improving future treatment strategies in respective patients.

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.