A proposed stratification system to address the heterogeneity of Subdural Hematoma Outcome reporting in the literature

A major challenge within the academic literature on SDHs has been inconsistent outcomes reported across studies. Historically, patients have been categorized by the blood-product age identified on imaging (i.e., acute, subacute, or chronic). However, this schematic has likely played a central role in producing the heterogeneity encountered in the literature. In this investigation, a total of 494 patients that underwent SDH evacuation at a tertiary medical center between November 2013-December 2021 were retrospectively identified. Mechanism of injury was reviewed by the authors and categorized as either positive or negative for a high-velocity impact (HVI) injury. Any head strike injury leading to the formation of a SDH while traveling at a velocity beyond that of normal locomotion or daily activities was categorized as an HVI. Patients were subsequently stratified by those with an acute SDHs after a high-velocity impact (aSDHHVI), those with an acute SDH without a high-velocity impact injury (aSDHWO), and those with any combination of subacute or chronic blood products (mixed-SDH [mSDH]). Nine percent (n = 44) of patients experienced an aSDHHVI, 23% (n = 113) aSDHWO, and 68% (n = 337) mSDH. Between these groups, highly distinct patient populations were identified using several metrics for comparison. Most notably, aSDHHVI had a significantly worse neurological status at discharge (50% vs. 23% aSDHWO vs. 8% mSDH; p < 0.001) and mortality (25% vs. 8% aSDHWO vs. 4% mSDH; p < 0.001). Controlling for gender, midline shift (mm), and anticoagulation use in the acute SDH population, multivariable logistic regression revealed a 6.85x odds ratio (p < 0.001) for poor outcomes in those with a positive history for a high-velocity impact injury. As such, the distribution of patients that suffer an HVI related acute SDH versus those that do not can significantly affect the outcomes reported. Adoption of this stratification system will help address the heterogeneity of SDH reporting in the literature while still closely aligning with conventional reporting.

Embolization of Middle Meningeal Arteries for Symptomatic Subacute Subdural Hematoma in Patients with Cancer

PURPOSE

The purpose of this study was to evaluate the technical and clinical success of middle meningeal artery (MMA) embolization performed for symptomatic subacute subdural hematoma (SDH) in patients with cancer.

METHODS

This study retrospectively included 23 consecutive patients (12 men, 11 women; median age 61 years, interquartile range: 55.5-75.5) who underwent 34 MMA angiograms for symptomatic SDH in 2022 and 2023. Median SDH thickness was 10.5 mm (7-12). Median platelet count was 117 K/mcL (54.5-218). 10 patients (43.5%, 10/23) had hematologic malignancies, seven patients (30.4%, 7/23) had surgery. Fluoroscopy time (FT), reference dose (RD), and kerma area product (Kap) were analyzed. Adverse events and outcomes were recorded.

RESULTS

The median imaging and clinical follow-up were 65 days (36.5-190.5) and 163 days (86-274), respectively. The technical success rate was 91.2% (31/34) as three MMA were not identified in two patients. Median procedure duration was 61 min (55.5-75.5). Median FT was 21.6 min (15.5-31.8); median RD was 158 mGy (96-256); and median Kap was 32.9 Gy.cm2 (20.4-45.1). No further intervention was needed. For 16 patients, SDH resolved after in median 59.5 days (50-90). For seven patients, SDH remained visible on the last imaging follow-up performed at 24 days in median (6.5-36.5). No predictive factor of failure was identified. The adverse event rate was 1/23 (4.3%). Eight patients (34.8%, 8/23) died during follow-up from progression of cancer.

CONCLUSION

MMA embolization of symptomatic SDH in patients with cancer appears safe and is associated with improvement in clinical symptoms.

Middle meningeal artery embolization reduces recurrence following surgery for septated chronic subdural hematomas

BACKGROUND

Septated chronic subdural hematomas (cSDH) have high rates of recurrence despite surgical evacuation. Middle meningeal artery embolization (MMAE) has emerged as a promising adjuvant for secondary prevention, yet its efficacy remains ill-defined.

METHODS

This is a retrospective review of septated cSDH cases treated at our institution. The surgery-only group was derived from cases performed before 2018, and the surgery+MMAE group was derived from cases performed 2018 or later. The primary outcome was reoperation rate. Secondary outcomes were recurrence, change in hematoma thickness, and midline shift.

RESULTS

A total of 34 cSDHs in 28 patients (surgery+MMAE) and 95 cSDHs in 83 patients (surgery-only) met the inclusion criteria. No significant difference in baseline characteristics between groups was identified. The reoperation rate was significantly higher in the surgery-only group (n = 16, 16.8%) compared with the surgery+MMAE cohort (n = 0, 0.0%) (p=0.006). A reduced incidence of recurrence (p=0.011) was also seen in the surgery+MMAE group.

CONCLUSIONS

MMAE for septated cSDH was found to be highly effective in preventing recurrence and reoperation. MMAE is an adjunct to surgical evacuation may be of particular benefit in this patient cohort.

Middle Meningeal Artery Embolization in Acute Leukemia Patients Presenting With Subdural Hematoma

Intracerebral hemorrhage is a potentially fatal complication in patients with acute leukemia and contributing factors include thrombocytopenia and coagulopathy. Patients with acute leukemia may develop subdural hematoma (SDH) spontaneously or secondary to trauma. In patients with acute leukemia and SDH, the surgical evacuation of the hematoma causes significant morbidity and mortality. New approaches and strategies to reduce the need for surgical evacuation are needed to improve outcomes in patients with acute leukemia and intracerebral hemorrhage. We report two cases of acute SDH in patients with acute leukemia successfully treated with middle meningeal artery embolization, a minimally invasive interventional radiology technique, obviating the need for a surgical intervention. The first patient with acute promyelocytic leukemia (APL) presented with coagulopathy and developed an acute SDH after a fall. The second patient with acute myeloid leukemia presented with gum bleeding and also sustained an acute SDH after a fall. Both patients underwent middle meningeal artery embolization for treating their SDHs while actively receiving induction chemotherapy for acute leukemia. Both patients had resolution of their acute SDH and are in remission from their acute leukemia. Middle meningeal artery embolization is a very effective, and within the context of this setting, a novel, minimally invasive technique for management of SDH in acute leukemia patients, which can prevent the need for surgical interventions with its associated comorbidities and high risk of fatal outcomes in patients with acute leukemia and acute SDH.

Chronic Subdural Hematoma Drainage under Local versus General Anesthesia: Systematic Review and Meta-Analysis

BACKGROUND

Chronic subdural hematoma (CSDH) is one of the most frequently encountered neurosurgical conditions. Although the mainstay treatment of chronic subdural hematoma has been burr-hole drainage, no consensus yet exists on the optimal anesthetic strategy between general anesthesia (GA) and local anesthesia (LA). This systematic review compares postoperative outcomes after CSDH evacuation under LA and GA.

METHODS

A search was conducted in MEDLINE (1946 to November 2023), Embase (1974 to November 2023), and PubMed (up to November 2023). We followed the PRISMA guidelines to systematically screen studies.

RESULTS

Our literature search identified 629 studies, out of which 12 were included. There were 1035 patients in the LA group and 699 patients in the GA group. Our meta-analysis found that the LA group had significantly shorter operative time (mean difference, -29.28 minutes; P < 0.0001), length of admission (mean difference, -1.58 days; 95% confidence interval [CI], -2.40 to -0.76 days; P = 0.0002), and postoperative complications rate (odds ratio [OR], 0.38; 95% CI, 0.25-0.59; P < 0.0001) compared with GA. There was no significant difference between the 2 groups in revision rate (OR, 0.77; 95% CI, 0.39-1.51; P = 0.45) and mortality (OR, 1.23; 95% CI, 0.63-2.43; P = 0.55).

CONCLUSIONS

In this meta-analysis, LA shows benefits in shorter operative time, shorter admission length, and fewer postoperative complications. This finding makes LA a less invasive alternative to GA, especially in elderly patients.

Pediatric head injuries: particularities and neurosurgical experience in a lower-middle income country

PURPOSE

To the best of our knowledge, this is the first study conducted in Tunisia on the neurosurgical management of child cranial trauma. The objectives of the present work were to identify the causes of pediatric head injuries, explore epidemiological and clinical specificities, and analyze the short- and long-term postoperative evolution.

METHODS

A retrospective review was conducted on one hundred children with head injuries over a five-year period at one of the largest neurosurgery departments in Tunisia. The collected data encompassed demographic information, clinical presentation features, neuroimaging characteristics, surgical management, complications, and outcomes.

RESULTS

Over a five-year period, we have found 118 children who have undergone surgery, representing an annual incidence of twenty-four children per year. The average age was 10 years. Falls emerged as the primary cause of childhood head injuries in our series, followed by road traffic accidents. The most frequently encountered initial sign was the loss of consciousness (52%), followed by headaches (28%), vomiting (25%), and seizures (8%). The average time between the accident and admission to the operating unit was 10 h. Various neurosurgeries were performed, with the evacuation of an epidural hematoma being the most common procedure. At a median follow-up of 24 months, the outcomes were favorable in 88% of cases.

CONCLUSION

The main prognostic factors for head trauma in children included age, circumstances of the accident, association with polytrauma, the initial Glasgow Coma Scale, the nature of the initial cerebral lesions, and the timeliness and quality of initial management.

Primary extranodal marginal zone mucosa-associated lymphoid tissue-type B-cell lymphoma involving the dura: A case report

Background

Primary extranodal marginal zone mucosa-associated lymphoid tissue-type B-cell lymphoma (EMZMBCL), which presents as a dural mass, is a rare intracranial tumor that mimics a subdural hematoma or meningioma.

Case Description

A 49-year-old woman presented to our hospital with transient right upper limb paresis, dysarthria for 10 min, and ongoing right upper-limb numbness. Computed tomography (CT) of the head revealed extra-axial lesions in the left frontal and parietal lobes. Based on the initial CT findings in the emergency room, an acute subdural hematoma was suspected. However, meningiomas and other intracranial tumors were also listed as differential diagnoses because there was no history of head trauma or coagulation abnormalities on blood examination, and further imaging studies were performed. Imaging findings suggested a subdural neoplastic lesion. A partial resection was performed for the lesion. Based on histopathological and immunohistochemical examinations, the patient was diagnosed with EMZMBCL. Whole-brain and intensity-modulated radiation therapies were administered as adjuvant therapies. The patient was discharged without neurological deficits.

Conclusion

EMZMBCL is a rare disease that should be considered in the differential diagnosis of subdural lesions, especially when there is no history of trauma or abnormalities in the coagulation system. The patient had a favorable outcome after selecting radiotherapy as the adjuvant therapy.

Correlating Age and Hematoma Volume with Extent of Midline Shift in Acute Subdural Hematoma Patients: Validation of an Artificial Intelligence Tool for Volumetric Analysis

OBJECTIVE

Decision for intervention in acute subdural hematoma patients is based on a combination of clinical and radiographic factors. Age has been suggested as a factor to be strongly considered when interpreting midline shift (MLS) and hematoma volume data for assessing critical clinical severity during operative intervention decisions for acute subdural hematoma patients. The objective of this study was to demonstrate the use of an automated volumetric analysis tool to measure hematoma volume and MLS and quantify their relationship with age.

METHODS

A total of 1789 acute subdural hematoma patients were analyzed using qER-Quant software (Qure.ai, Mumbai, India) for MLS and hematoma volume measurements. Univariable and multivariable regressions analyzed association between MLS, hematoma volume, age, and MLS:hematoma volume ratio.

RESULTS

In comparison to young patients (≤ 70 years), old patients (>70 years) had significantly higher average hematoma volume (old: 62.2 mL vs. young 46.8 mL, P < 0.0001), lower average MLS (old: 6.6 mm vs. young: 7.4 mm, P = 0.025), and lower average MLS:hematoma volume ratio (old: 0.11 mm/mL vs. young 0.15 mm/mL, P < 0.0001). Young patients had an average of 1.5 mm greater MLS for a given hematoma volume in comparison to old patients. With increasing age, the ratio between MLS and hematoma volume significantly decreases (P = 0.0002).

CONCLUSIONS

Commercially available, automated, artificial intelligence (AI)-based tools may be used for obtaining quantitative radiographic measurement data in patients with acute subdural hematoma. Our quantitative results are consistent with the qualitative relationship previously established between age, hematoma volume, and MLS, which supports the validity of using AI-based tools for acute subdural hematoma volume estimation.

Dialysis disequilibrium syndrome in neurosurgery: literature review and illustrative case example

INTRODUCTION

The dialysis disequilibrium syndrome (DDS) is a complication in those undergoing dialysis for chronic kidney disease (CKD) or acute kidney injury (AKI), characterized by nonspecific symptoms that may progress to coma and death secondary to cerebral edema. This syndrome is associated with rapid change in electrolytes during dialysis with changes in intracranial pressure (ICP) and may have a higher incidence in the elderly neurosurgical patient population.

METHODS

Literature review and illustrative case example.

RESULTS

A 62-year-old female presented with acute mental status change during hemodialysis (HD), with a history of a nonsurgical acute subdural hematoma (SDH) 10 days prior. Imaging showed a conversion of the acute SDH to chronic SDH of 12.2 mm in size with a 14.1 midline shift, for which she underwent a hemicraniectomy with SDH evacuation, with a gradual return to baseline. The literature review identified 5 publications meeting the inclusion criteria. Major theories of DDS include a reverse urea effect, intracerebral acidosis, idiogenic osmoles, and local inflammation. This complication may occur more frequently in the elderly neurosurgical patient population, likely due to age-related comorbidities, preexisting neurological insult, and increased permeability of the blood-brain barrier (BBB), leading to cerebral edema.

CONCLUSION

DDS is a rare and potentially fatal complication of HD that may have a higher incidence in the elderly neurosurgical patient population, yet remains to be fully understood. Further study is recommended to characterize the pathophysiological mechanism and incidence of DDS in neurosurgical patients.

craniotomy

OBJECTIVE

Acute subdural hematoma (ASDH) stands as a significant contributor to morbidity after severe traumatic brain injuries (TBI). The primary treatment approach for patients experiencing progressive neurological deficits or notable mass effects is the surgical removal of the hematoma, which can be achieved through craniotomy (CO) or decompressive craniectomy (DC). Nevertheless, the choice between these two procedures remains a subject of ongoing debate and controversy.

MATERIALS AND METHODS

We conducted a comprehensive literature review, utilizing prominent online databases and manually searching references related to craniotomy and craniectomy for subdural hematoma evacuation up to November 2023. Our analysis focused on outcome variables such as the presence of residual subdural hematoma, the need for revision procedures, and overall clinical outcomes.

RESULTS

We included a total of 11 comparative studies in our analysis, encompassing 4269 patients, with 2979 undergoing craniotomy and 1290 undergoing craniectomy, meeting the inclusion criteria. Patients who underwent craniectomy displayed significantly lower scores on the Glasgow Coma Scale (GCS) during their initial presentation. Following surgery, the DC group exhibited a significantly reduced rate of residual subdural (P = 0.009). Additionally, the likelihood of a poor outcome during follow-up was lower in the CO group. Likewise, the mortality rate was lower in the CO group compared to the craniectomy group (OR 0.63, 95% CI 0.41-0.98, I2 = 84%, P = 0.04).

CONCLUSION

Our study found that CO was associated with more favorable outcomes in terms of mortality, reoperation rate, and functional outcome while DC was associated with less likelihood of residual subdural hematoma. Upon further investigation of patient characteristics who underwent into either of these interventions, it was very clear that patients in DC cohort have more serious and low pre-op characteristics than the CO group. Nonetheless, brain herniation and advanced age act as independent factor for predicting the outcome irrespective of the intervention.

Spontaneous intracranial hypotension presenting with bilateral subdural hematoma: Decision-making and treatment strategies

BACKGROUND

The timing and decision to drain subdural hematoma (SDH) in spontaneous intracranial hypotension (SIH) remains a dilemma. We reviewed our experience of bilateral SDH secondary to SIH, focusing on decision making and treatment strategies.

METHODS

We retrospectively reviewed bilateral SDH secondary to SIH between March 2010 and September 2021. Baseline characteristics of patients, diagnosis, radiologic findings, treatments, and clinical outcome were investigated.

RESULTS

Fifteen patients (7 men, 8 women) with bilateral SDH secondary to SIH were included in this study. Initially, patients were treated conservatively (4 patients, 26.7 %), with an epidural blood patch (EBP, 3 patients, 20.0 %), and SDH drainage followed by the Trendelenburg position (8 patients, 53.3 %). All 3 patients that were initially treated with EBP required SDH drainage. Of the 8 patients initially treated with SDH drainage via burr hole followed by Trendelenburg position, 7 patients showed sustained improvements without EBP; however, 1 patient needed EBP. Deterioration to coma occurred in 6 out of 15 patients (40.0 %). All 6 deteriorated patients immediately recovered after SDH drainage with Trendelenburg position; 5 achieved sustained improvement without EBP and 1 required EBP. During the follow-up period, 14 out of 15 patients (93.3 %) showed good recovery.

CONCLUSIONS

Evacuation of SDH is not always necessary in SIH; however, we did not hesitate to perform hematoma drainage, in deteriorated patients or those with thick hematoma that is associated with significant sagging and cistern effacement. This can prevent irreversible neurologic complications. Moreover, the Trendelenburg position may help to achieve sustained improvement without additional treatment.

Prognostic factors and clinical nomogram for in-hospital mortality in traumatic brain injury

BACKGROUND

Traumatic brain injury (TBI) is a major cause of death and functional disability in the general population. The nomogram is a clinical prediction tool that has been researched for a wide range of medical conditions. The purpose of this study was to identify prognostic factors associated with in-hospital mortality. The secondary objective was to develop a clinical nomogram for TBI patients' in-hospital mortality based on prognostic factors.

METHODS

A retrospective cohort study was conducted to analyze 14,075 TBI patients who were admitted to a tertiary hospital in southern Thailand. The total dataset was divided into the training and validation datasets. Several clinical characteristics and imaging findings were analyzed for in-hospital mortality in both univariate and multivariable analyses using the training dataset. Based on binary logistic regression, the nomogram was developed and internally validated using the final predictive model. Therefore, the predictive performances of the nomogram were estimated by the validation dataset.

RESULTS

Prognostic factors associated with in-hospital mortality comprised age, hypotension, antiplatelet, Glasgow coma scale score, pupillary light reflex, basilar skull fracture, acute subdural hematoma, subarachnoid hemorrhage, midline shift, and basal cistern obliteration that were used for building nomogram. The predictive performance of the nomogram was estimated by the training dataset; the area under the receiver operating characteristic curve (AUC) was 0.981. In addition, the AUCs of bootstrapping and cross-validation methods were 0.980 and 0.981, respectively. For the temporal validation with an unseen dataset, the sensitivity, specificity, accuracy, and AUC of the nomogram were 0.90, 0.88, 0.88, and 0.89, respectively.

CONCLUSION

A nomogram developed from prognostic factors had excellent performance; thus, the tool had the potential to serve as a screening tool for prognostication in TBI patients. Furthermore, future research should involve geographic validation to examine the predictive performances of the clinical prediction tool.

Analysis of middle meningeal artery embolization for the treatment of chronic, acute on chronic, and subacute subdural hematomas

Background

Chronic subdural hematoma (cSDH) is a common sequela of traumatic brain injury. Middle meningeal artery embolization (MMAE) has shown promising results as an emerging minimally invasive alternative treatment. The purpose of this study is to examine the safety and efficacy of MMAE performed in patients with cSDH, acute-on-chronic, and subacute SDH with a traumatic etiology.

Methods

This retrospective study included cases performed at a Level II Trauma Center between January 2019 and December 2020 for MMAE of cSDHs. Data collected included patient demographic characteristics and comorbidities, SDH characteristics, complications, and efficacy outcomes. The lesion measurements were collected before the procedure, 4-6 weeks and 3-6 months post-procedure.

Results

In our patient population, 78% (39) either had lesions improve or completely resolved. The sample included 50 patients with a mean age of 74 years old. Statistically significant reductions in lesion size were found from pre- to post-procedure in the left lesions, right lesions, and midline shifts. The left lesions decreased from 13.88 ± 5.70 mm to 3.19 ± 4.89 mm at 3-6 months with P < 0.001. The right lesions decreased from 13.74 ± 5.28 mm to 4.93 ± 7.46 mm at 3-6 months with P = 0.02. Midline shifts decreased from 3.78 ± 3.98 mm to 0.48 ± 1.31 mm at 3-6 months with P = 0.02. No complications were experienced for bleeding, hematoma, worsening SDH, pseudoaneurysm, or stroke.

Conclusion

Our pilot study from a single center utilizing MMAE demonstrates that MMAE is successful without increasing treatment-related complications not only for cSDH but also in acute-on-cSDH and SDH with a subacute component.

Efficacy and safety of bedside percutaneous three-millimeter twist-drill trephination under local anesthesia-a retrospective study of 1000 patients

PURPOSE

Percutaneous 3-mm twist-drill trephination (TDT) under local anesthesia as a bedside operative technique is an alternative to the conventional open surgical trephination in the operating theatre. The aim of this study was to verify the efficacy and safety of this minimal invasive procedure.

METHODS

This retrospective study comprises 1000 patients who were treated with TDT under local anesthesia at bedside due to chronic subdural hematoma (cSDH), intracerebral hemorrhage (ICH), and hydrocephalus (HYD) as a result of subarachnoid hemorrhage or non-hemorrhagic causes, increased intracranial pressure (IIP) in traumatic brain injury or non-traumatic brain edema, and other pathologies (OP) requiring drainage. Medical records, clinical outcome, and results of pre- and postoperative computed tomography (CT) and/or magnetic resonance tomography (MRT) were analyzed.

RESULTS

Indications for TDT were cSDH (n = 275; 27.5%), ICH (n = 291; 29.1%), HYD (n = 316; 31.6%), IIP (n = 112; 11.2%), and OP (n = 6; 0.6%). Overall, primary catheter placement was sufficient in 93.8% of trephinations. Complication rate was 14.1% and mainly related to primary catheter malposition (6.2%), infections (5.2%), and secondary hemorrhage (2.7%); the majority of which were clinically inapparent puncture channel bleedings not requiring surgical intervention. The revision rate was 13%.

CONCLUSIONS

Bedside TDT under local anesthesia has proven to be an effective and safe alternative to the conventional burr-hole operative technique as usually performed under general anesthesia in the operation theatre, and may be particularly useful in emergency cases as well as in elderly and multimorbid patients.

Factors influencing the development of infantile traumatic brain injury with a biphasic clinical course and late reduced diffusion

BACKGROUND

Infantile traumatic brain injury (TBI) with a biphasic clinical course and late reduced diffusion (TBIRD) has been reported as a type of TBI. However, it remains uncertain which pediatric patients with TBI develop TBIRD.

METHODS

Patients with TBI who were admitted to our hospital and underwent magnetic resonance imaging (MRI) between December 2006 and October 2022 were included in this study. A diagnosis of TBIRD was made in patients with or suspected TBI, with initial symptoms being convulsions or disturbance of consciousness and late-onset subcortical reduced diffusion, the so-called bright tree appearance. Clinical features, neuroimaging (computed tomography (CT) and MRI) findings, laboratory data, and Tada score were retrospectively compared between TBIRD and non-TBIRD patients. Neurological prognosis was assessed using the Pediatric Cerebral Performance Category scale.

RESULTS

Of 21 patients who met the inclusion criteria, a diagnosis of TBIRD was made in 7 patients (median age: 8 months). The factors contributing to TBIRD development were seizures lasting over 30 min as the initial symptom (5/7 in TBIRD vs. 0/14 in non-TBIRD), tracheal intubation during initial treatment (5/7 vs. 0/14), and brain parenchymal lesions on CT (3/7 vs. 0/14), suggesting that severe TBI may progress to TBIRD. The Tada score was more positive in patients with TBIRD (6/7) than in those without (0/14).

CONCLUSIONS

It is important to monitor infant patients with severe TBI for the development of TBIRD. The Tada score can be a useful tool for TBIRD prediction.

Aneurysmal Subdural Hematoma: A Systematic Review

BACKGROUND

Aneurysmal subdural hematoma (aSDH) is a rare complication of aneurysm rupture, affecting between 0.5 and 7.9% of patients with aneurysmal subarachnoid hemorrhage (aSAH). The clinical presentation, course, and outcomes of these patients are largely unknown.

OBJECTIVE

This study aims to systematically review the literature to evaluate the demographics, clinical presentation, aneurysm location, treatment options, and outcomes of patients with aSDH with and without aSAH.

METHODS

In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, we conducted a systematic review of three databases (PubMed, EMBASE, and Google Scholar). From identified reports, we extracted data on patients' demographics, clinical presentation, imaging findings, surgical interventions, and clinical outcomes. We compared clinical outcomes, need for surgical treatment, and aneurysm location between patients with aSDH with and without concurrent aSAH using χ2 and Fisher's exact tests. We used simple and multivariable logistic regression models to further examine the association between the presence of aSAH and surgical treatment with clinical outcomes.

RESULTS

We identified 112 articles with a total of 270 patients (70% women, mean age 52.8 [± 15.5] years). The most common aneurysm locations were the middle cerebral artery, followed by the posterior communicating artery, and the internal carotid artery. Patients with isolated aSDH fully recovered more frequently than those with concomitant aSAH (38% vs. 6%). The presence of aSAH increased the odds of unfavorable outcome (odds ratio [OR] 2.68, 95% confidence interval [CI] 1.34-5.37). Surgical treatment was inversely associated with unfavorable outcome in the univariable (OR 0.48, 95% CI 0.28-0.84) but not in the multivariable analysis (OR 0.76, 95% CI 0.35-1.66).

CONCLUSION

aSDH occurs infrequently. Simultaneous presence of both aSDH and aSAH from an aneurysmal source is associated with poor outcomes. Surgical treatment is associated with lower rates of unfavorable outcomes including death and severe disability.

Vitamin D accelerates the subdural hematoma clearance through improving the meningeal lymphatic vessel function

Subdural hematoma (SDH) drains into the extracranial lymphatic system through the meningeal lymphatic vessels (mLVs) but the formation of SDH impairs mLVs. Because vitamin D (Vit D) can protect the endothelial cells, we hypothesized that Vit D may enhance the SDH clearance. SDH was induced in Sprague-Dawley rats and treated with Vit D or vehicle. Hematoma volume in each group was measured by H&E staining and hemoglobin quantification. Evans blue (EB) quantification and red blood cells injection were used to evaluated the drainage of mLVs. Western blot analysis and immunofluorescence were conducted to assess the expression of lymphatic protein markers. We also examined the inflammatory factors levels in subdural space by ELISA. Vit D treatment significantly reduced SDH volume and improved the drainage of SDH to cervical lymph nodes. The structure of mLVs in SDH rats were protected by Vit D, and the expressions of LYVE1, PROX1, FOXC2, and VE-cadherin were increased after Vit D treatment. The TNF-α, IL-6, and IL-8 levels were reduced in Vit D group. In vitro, Vit D also increased the VE-cadherin expression levels under inflammation. Vit D protects the structure of mLVs and enhances the absorption of SDH, partly by the anti-inflammatory effect of Vit D.

Extreme-aged patients (≥ 85 years) experience similar outcomes as younger geriatric patients following chronic subdural hematoma evacuation: a matched cohort study

Subdural hematoma (SDH) evacuation represents one of the most frequently performed neurosurgical procedures. Several reports cite a rise in both the age and number of patient's requiring treatment, due in part to an aging population and expanded anticoagulation use. However, limited data and conflicting conclusions exist on extreme-aged geriatric patients (≥ 85 years of age) after undergoing surgery. Patients undergoing SDH evacuation at a tertiary academic medical center between November 2013-December 2021 were retrospectively identified. The study group consisted of patients ≥ 85 years (Group 1) diagnosed with a chronic SDH surgically evacuated. A control group was created matching patients by 70-84 years of age, gender, and anticoagulation use (Group 2). Multiple metrics were evaluated between the two including length-of hospital-stay, tracheostomy/PEG placement, reoperation rate, complications, discharge location, neurological outcome at the time of discharge, and survival. A total of 130 patients were included; 65 in Group 1 and 65 in Group 2. Patient demographics, medical comorbidities, SDH characteristics, international normalized ratio, partial thromboplastin time, and use of blood thinning agents were similar between the two groups. Kaplan Meier survival analysis at one-year was 80% for Group 1 and 76% for Group 2. No significant difference was identified using the log-rank test for equality of survivor functions (p = 0.26). All measured outcomes including GCS at time of discharge, length of stay, rate of reoperations, and neurological outcome were statistically similar between the two groups. Backwards stepwise conditional logistic regression revealed no significant association between poor outcomes at the time of discharge and age. Alternatively, anticoagulation use was found to be associated with poor outcomes (OR 3.55, 95% CI 1.08-11.60; p = 0.036). Several outcome metrics and statistical analyses were used to compare patients ≥ 85 years of age to younger geriatric patients (70-84 years) in a matched cohort study. Adjusting for age group, gender, and anticoagulation use, no significant difference was found between the two groups including neurological outcome at discharge, reoperation rate, and survival.

Surgical evacuation for chronic subdural hematoma: Predictors of reoperation and functional outcomes

Background

Although chronic subdural hematoma (CSDH) incidence has increased, there is limited evidence to guide patient management after surgical evacuation.

Objective

To identify predictors of reoperation and functional outcome after CSDH surgical evacuation.

Methods

We identified all patients with CSDH between 2010 and 2018. Clinical and radiographic variables were collected from the medical records. Outcomes included reoperation within 90 days and poor (3-6) modified Rankin Scale score at 3 months.

Results

We identified 461 surgically treated CSDH cases (396 patients). The mean age was 70.1 years, 29.7 % were females, 298 (64.6 %) underwent burr hole evacuation, 152 (33.0 %) craniotomy, and 11 (2.4 %) craniectomy. Reoperation rate within 90 days was 12.6 %, whereas 24.2 % of cases had a poor functional status at 3 months. Only female sex was associated with reoperation within 90 days (OR = 2.09, 95 % CI: 1.17-3.75, P = 0.013). AMS on admission (OR = 5.19, 95 % CI: 2.15-12.52, P < 0.001) and female sex (OR = 3.90, 95 % CI: 1.57-9.70, P = 0.003) were independent predictors of poor functional outcome at 3 months.

Conclusion

Careful management of patients with the above predictive factors may reduce CSDH reoperation and improve long-term functional outcomes. However, larger randomized studies are necessary to assess long-term prognosis after surgical evacuation.

Quantifying the effect of cerebral atrophy on head injury risk in elderly individuals: Insights from computational biomechanics and experimental analysis of bridging veins

The objective of this study was to quantitatively investigate the relationship between cerebral atrophy and the risk of injury in elderly individuals. To achieve this, a sophisticated computational biomechanics approach utilizing finite element analysis was employed to simulate the mechanical behavior of the brain and skull under various conditions. In addition, particular emphasis was placed on understanding the role of cerebral bridging veins (BVs) and their mechanical properties at different ages in the occurrence of head injuries. Head models representing healthy brains and five atrophy models were developed based on imaging data. After validation, the models underwent the identical impact loading conditions to enable the simulation of brain damage. The resulting outcomes of the models with brain atrophy were then compared to the results obtained from the healthy model, allowing for a comparative analysis. Simulations showed increased relative displacement with worsening brain atrophy, particularly in the frontal and occipital regions. Compared to the healthy brain model, relative displacement increased by 2.36 %-9.21 % in the atrophy models, indicating an elevated risk of injury. In severe brain atrophy (FEM 6), the strain reached 83.59 % in local model simulations, leading to damage and rupture of cerebral BVs in both young and elderly individuals. Mechanical tests on cerebral BVs demonstrated a negative correlation between age and ultimate force, stress, and strain, suggesting increased susceptibility to damage with age. An observed sharp decline of approximately 50 % in ultimate stress and 35 % in ultimate strain was noted as age increased. We implemented a 50 % reduction in the intensity of head impact forces; nevertheless, vascular damage continues to manifest in the elderly population. To establish a truly safe zone, it is imperative to further decrease the intensity of the impact. This investigation represents a significant step forward in our understanding of the complex interplay between cerebral atrophy, the mechanical properties of BVs at different age, and the risk of head injury in the elderly. Through continued research in this field, we can strive to improve the quality of care, enhance prevention strategies, and ultimately enhance the well-being and safety of the elderly population.

Predictors of mortality in chronic subdural hematoma evacuation

Chronic subdural hematoma (cSDH) is one of the most common types of intracranial hemorrhages, particularly in the elderly. Despite extensive research regarding cSDH diagnosis and treatment, there is conflicting data on predictors of postoperative mortality (POM). We conducted a large retrospective review of patients who underwent a cSDH evacuation at a single urban institution between 2015 and 2022. Data were collected from the electronic medical record on prior comorbidities, anticoagulation use, mental status on presentation, preoperative labs, and preoperative/postoperative imaging parameters. Univariate and multivariate analyses were conducted to analyze predictors of mortality. Mortality during admission for this cohort was 6.1%. Univariate analysis showed the mortality rate was higher in those presenting with a history of dialysis. In addition, those who presented with altered mental status, were intubated, and lower GCS scores had higher rates of POM. Usage of Coumadin was correlated with higher rates of POM. Examination of preoperative labs showed that patients who presented with anemia or thrombocytopenia had higher POM. Imaging data showed that cSDH volume and greatest dimension were correlated with higher rates of POM. Finally, patients that were not extubated postoperatively had higher rates of POM. Multivariate analysis showed that only altered mental status and being not being extubated postoperatively were correlated with a higher risk of mortality. In summation, we demonstrated that altered mental status and failure to extubate were independent predictors or mortality in cSDH evacuation. Interestingly, patient age was not a significant predictor of mortality.

Thromboembolic prophylaxis in spine surgery: an analysis of ChatGPT recommendations

BACKGROUND CONTEXT

Venous thromboembolism is a negative outcome of elective spine surgery. However, the use of thromboembolic chemoprophylaxis in this patient population is controversial due to the possible increased risk of epidural hematoma. ChatGPT is an artificial intelligence model which may be able to generate recommendations for thromboembolic prophylaxis in spine surgery.

PURPOSE

To evaluate the accuracy of ChatGPT recommendations for thromboembolic prophylaxis in spine surgery.

STUDY DESIGN/SETTING

Comparative analysis.

PATIENT SAMPLE

None.

OUTCOME MEASURES

Accuracy, over-conclusiveness, supplemental, and incompleteness of ChatGPT responses compared to the North American Spine Society (NASS) clinical guidelines.

METHODS

ChatGPT was prompted with questions from the 2009 NASS clinical guidelines for antithrombotic therapies and evaluated for concordance with the clinical guidelines. ChatGPT-3.5 responses were obtained on March 5, 2023, and ChatGPT-4.0 responses were obtained on April 7, 2023. A ChatGPT response was classified as accurate if it did not contradict the clinical guideline. Three additional categories were created to further evaluate the ChatGPT responses in comparison to the NASS guidelines: over-conclusiveness, supplementary, and incompleteness. ChatGPT was classified as over-conclusive if it made a recommendation where the NASS guideline did not provide one. ChatGPT was classified as supplementary if it included additional relevant information not specified by the NASS guideline. ChatGPT was classified as incomplete if it failed to provide relevant information included in the NASS guideline.

RESULTS

Twelve clinical guidelines were evaluated in total. Compared to the NASS clinical guidelines, ChatGPT-3.5 was accurate in 4 (33%) of its responses while ChatGPT-4.0 was accurate in 11 (92%) responses. ChatGPT-3.5 was over-conclusive in 6 (50%) of its responses while ChatGPT-4.0 was over-conclusive in 1 (8%) response. ChatGPT-3.5 provided supplemental information in 8 (67%) of its responses, and ChatGPT-4.0 provided supplemental information in 11 (92%) responses. Four (33%) responses from ChatGPT-3.5 were incomplete, and 4 (33%) responses from ChatGPT-4.0 were incomplete.

CONCLUSIONS

ChatGPT was able to provide recommendations for thromboembolic prophylaxis with reasonable accuracy. ChatGPT-3.5 tended to cite nonexistent sources and was more likely to give specific recommendations while ChatGPT-4.0 was more conservative in its answers. As ChatGPT is continuously updated, further validation is needed before it can be used as a guideline for clinical practice.

Middle Meningeal Artery Embolization for Subdural Hematoma: An Institutional Cohort and Propensity Score-Matched Comparison with Conventional Management

BACKGROUND

The treatment of non-acute subdural hematoma (NASDH) is challenging due to its high recurrence rates and comorbidities of mostly elderly patients. Middle meningeal artery embolization (MMAE) recently emerged as an alternative to surgery in the treatment of NASDH.

OBJECTIVE

To describe a single center's experience of MMAE with Onyx for NASDH and compare it to a surgically treated historical cohort.

METHODS

We performed a retrospective analysis of patients undergoing MMAE for NASDH from 2019 to 2021. MMAE was performed with ethylene vinyl alcohol copolymer (Onyx). Comparisons were made with a historical cohort from 2010 to 2018 who underwent surgical evacuation only, before and after propensity score matching. Outcomes were assessed clinically and radiographically.

RESULTS

We included 44 consecutive patients (55 MMAEs) who underwent MMAE, with a median follow-up of 63.5 days. Twenty-four NASDHs underwent upfront embolization, 17 adjunctive, and 14 for recurrence after prior surgical evacuation, with no significant differences in hematoma and mRS reduction between them. Two patients died during hospitalization and 2 during follow-up, unrelated to the procedure. Mean SDH thickness decreased by 48.3% ± 38.1% (P < 0.001) on last follow-up, which did not correlate with the amount of Onyx injected. Six (13.6%) patients required surgical rescue after embolization. There were no procedure-related complications. The mean modified Rankin Scale (mRS) on admission was 2.8 ± 1.5, which decreased significantly to 1 [1,4] at the last follow-up (P = 0.033). The MMAE (41 hematomas; upfront and adjunctive embolization) and Surgical Evacuation-only (461 hematomas) cohorts were balanced with propensity score mathing. Matching was successful for 41 MMAE and 41 surgical-only hematoma pairs, and only hypertension remained significantly different between the two groups, but there was no significant difference in any outcome.

CONCLUSION

MMAE for NASDH seems safe and effective in appropriately selected patients, non-inferior to surgery, and may become a minimally-invasive alternative. Given our encouraging results, large-scale clinical randomized trials are warranted.

Double jeopardy: Successful management of a traumatic ascending aortic pseudoaneurysm with concurrent subdural hematoma

We present the case of a 59-year-old male who sustained an ascending aortic injury and a subdural hematoma after a head on collision. After undergoing emergent craniotomy for evacuation of the subdural hematoma, he was maintained with strict blood pressure control. Once able to be safely anticoagulated, he underwent replacement of the ascending aorta. This exceedingly rare case was managed by a multidisciplinary team approach that led to an optimal outcome given his disastrous multi-traumatic injuries.

The interdural hematoma: A subtype of convexity subdural/dural hematoma with specific radioanatomical characteristics

Background

Rare cases of biconvex hematomas splitting the convexity dura mater were reported and denominated interdural hematoma (IDH). Due to their rarity, little is known about their radiological characteristics, and in most cases, their invasive management with craniotomy and dural membrane excision is unnecessary.

Case Description

We report here a case of single burr-hole endoscopic evacuation of an IDH and its complete resolution after the 6-month follow-up imaging. The literature review reveals 11 reported cases of IDH. Most of them are male and the mean age is 65 years (range 51-90). Most of the reported IDHs were misdiagnosed as epidural hematoma or meningioma, and therefore, they have been managed invasively through craniotomy with dural excision. Diagnosis of the interdural nature was confirmed macroscopically during surgery in all cases and histology was reported for 6 cases. Image analysis found a double dural beak sign and biconvex shape on coronal planes, subarachnoid space enlargement at the collection extremities, and irregular thick inner wall as common radiological aspects of the IDH.

Conclusion

IDH is a rarely reported and often misdiagnosed dural hematoma subtype. Its invasive treatment through craniotomy is likely related to its unknown radiological characteristics. We review and raise awareness about potentially unique radiological anatomy that could avoid unnecessary invasive treatment. Moreover, we report the first case of endoscopically evacuated IDH with long-term follow-up imaging showing complete resolution.

Bilateral sixth nerve palsy with subdural hematoma: a unique presentation of B12 deficiency

Vitamin B12 is inextricably associated with the development and maintenance of neuronal functions. It is classically associated with subacute combined degeneration and peripheral neuropathy; however, cranial neuropathy is uncommon. We observed the rarest neurological manifestation of B12 deficiency. A 12 months infant had history of lethargy, irritability, anorexia, paleness, vomiting, and neurodevelopmental delay for 2 months. He also developed inattention and altered sleep pattern. His mother noticed bilateral inward rotation of both eyes. On examination, the infant had bilateral lateral rectus palsy. The infant was found to have anemia (7.7g/dL) and severe B12 deficiency (74pg/mL). On MRI, there was cerebral atrophy, subdural hematoma (SDH) and wide cisternal spaces and sulci. On supplementation with cobalamin, he improved clinically though mild restriction of lateral gaze on the left side persists. Follow up MRI showed significant improvement in cerebral atrophy with resolution of SDH. To date, such clinical presentation of B12 deficiency has never been reported. The authors suggest B12 supplementation for at risk population esp at antenatal stage and lactating mothers in national programs. The treatment of this condition should be initiated early to prevent long term sequelae.

Revisiting the canonical definition of heat hematoma: A rare case of postmortem subdural heat hematoma

Heat hematoma is generally recognized as a postmortem heat-induced artifact in extradural spaces found in burned bodies. Conversely, subdural hematoma in charred bodies is more indicative of antemortem trauma. Here, we present a rare case of a subdural heat hematoma in forensic practice. The subdural hematoma was found in a charred body that was determined to be dead before the fire without findings of antemortem head injury. Furthermore, the detailed determination and formation mechanism of this subdural heat hematoma are discussed. With this rare case, we propose a reconsideration of the canonical definition of heat hematoma. This report envisions benefitting forensic pathologists facing similar cases.

Spontaneous subdural hematoma in a young COVID-19-confirmed patient without comorbidities: A case report

The majority of acute subdural hematomas are due to trauma, and cases of spontaneous subdural hematoma are rare. This report aims to provide an overview of subdural hematoma associated with COVID-19 virus. We described a case of a 22-year-old female without comorbidities and confirmed COVID-19 with spontaneous subdural hematoma on non-contrast computed tomography scan. This was the first case encountered in our hospital. There is no published cases yet in the Philippines. Mechanisms linking cerebrovascular events to COVID-19 are hypothesized. First, it has been postulated that COVID virus is neurotropic toward angiotensinogen-converting enzyme-2 receptors and it can invade and directly damage cerebral vessels. Second, entry of the virus into the cells results in marked reduction in angiotensinogen-converting enzyme-2 levels which could contribute to the development of intracranial hemorrhage. Third, COVID-19 patients usually develop a systemic hyperinflammatory syndrome characterized by fulminant hypercytokinemia which may mediate vascular remodeling and predispose to intracranial hemorrhage. COVID infection should be considered as one of the differentials in patients presenting with neurological symptom. More research needs to be performed to understand the pathogenic mechanisms behind each of these disorders and better treat such patients with suitable drugs in a timely manner.

A clear presentation of intracranial hypostasis on PMCT

Intracranial hypostasis is a common postmortem change evident on postmortem CT (PMCT), but can be readily misinterpreted as subdural hematoma by inexperienced physicians. Although PMCT is necessarily lacking contrast enhancement, we reconstructed hypostatic sinuses into three-dimensional images resembling the results of in vivo venography. This simple methodology facilitates easy recognition of intracranial hypostasis.

Primary intracranial sarcoma masquerading as a chronic subdural haematoma: illustrative case and review of an unusual phenomenon

It is very unusual for a primary intracranial malignancy to present as a chronic subdural hematoma. This case report describes one such case in a 3-year-old girl who presented with raised intracranial pressure following a mild head injury. Imaging of her brain revealed bilateral chronic subdural hematomas with an enhancing subdural mass and multiple nodular lesions infiltrating the brain parenchyma. She underwent a craniotomy, drainage of the subdural collections and resection of the subdural mass. Histopathology revealed an undifferentiated sarcoma, and she was referred for adjuvant therapy. This case underlines the importance of evaluating paediatric subdural collections for a possible underlying malignancy, even in the background of a preceding head injury. The cause-effect relationship of sarcomas with subdural collections remains unclear because of the scarcity of available literature on the subject.

Spontaneous resorption of a convexity arachnoid cyst associated with intracystic hemorrhage and subdural hematoma: A case report

Background

Intracranial arachnoid cysts (ACs) are developmental anomalies usually filled with cerebrospinal fluid (CSF), rarely resolving throughout life. Here, we present a case of an AC with intracystic hemorrhage and subdural hematoma (SDH) that developed after a minor head injury before gradually disappearing. Neuroimaging demonstrated specific changes from hematoma formation to AC disappearance over time. The mechanisms of this condition are discussed based on imaging data.

Case Description

An 18-year-old man was admitted to our hospital with a head injury caused by a traffic accident. On arrival, he was conscious with a mild headache. Computed tomography (CT) revealed no intracranial hemorrhages or skull fractures but an AC was seen in the left convexity. One month later, follow-up CT scans showed an intracystic hemorrhage. Subsequently, an SDH appeared then both the intracystic hemorrhage and SDH gradually shrank, with the AC disappearing spontaneously. The AC was considered to have disappeared, along with the spontaneous SDH resorption.

Conclusion

We present a rare case where neuroimaging demonstrated spontaneous resorption of an AC combined with intracystic hemorrhage and SDH over time, which may provide new insights into the nature of adult ACs.

Spontaneous subdural hematoma concomitant with subarachnoid hemorrhage and intracerebral hemorrhage due to ruptured brain arteriovenous malformation treated with curative embolization

Introduction

An arteriovenous malformation (AVM) consists of a tangled cluster of dilated blood vessels forming anomalous communication between arterial and venous systems without capillary bridging. The most likely manifestations of a ruptured AVM are intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), or intraventricular hemorrhage (IVH). Subdural hematoma (SDH) is exceptional in cases of ruptured brain arteriovenous malformation (BAVM).

Case Report

A 30-year-old female was referred to the Emergency Room with a major complaint of sudden thunderclap headache 1 day before admission. The patient also complained of double vision and left ptosis that lasted for 1 day. There was no other complaint or history of hypertension, diabetes, or trauma. Non-contrast head computed tomography (CT) showed ICH-SAH-SDH on the left side of the brain which was not typical of a hypertensive pattern. The secondary ICH has a score of 6, indicating that 100% of the bleeding might be caused by underlying vascular malformation. Furthermore, cerebral angiography showed cortical plexiform BAVM on the left occipital lobe, and the patient underwent curative embolization.

Discussion

Spontaneous SDH is very rare, and there are some hypotheses about the reasons for its occurrence. First, brain movement stretches the arachnoid layer that adheres to the AVM, resulting in direct bleeding into subdural space. Second, high-flow pia-arachnoid ruptured blood might extravasate into subdural space. Finally, the ruptured cortical artery that connects the cortex and dura layer (bridging artery) might also cause SDH. Some scoring systems are useful in BAVM, and this study selected endovascular embolization for the patient.

Conclusion

Brain AVM rupture usually causes ICH, SAH, or IVH. Clinicians must be more aware of spontaneous SDH because it might be caused by a vascular malformation, although it is rare.

Spinal subdural hematoma in a patient with immune thrombocytopenic purpura following microvascular decompression: a rare case report

This article reports a case of spontaneous spinal subdural hematoma (SSDH) after brain surgery in a patient with immune thrombocytopenic purpura (ITP), reviews the relevant literature, and discusses the etiology, pathogenesis, and clinical features of SSDH in patients with ITP. A male patient in his early 50 s with an 8-year history of ITP and suffering from coexistent hemifacial spasm and trigeminal neuralgia underwent microvascular decompression in our department. His preoperative corrected platelet count was within the normal range. On postoperative day 2, the patient complained of acute low back pain and sciatica. Lumbar magnetic resonance imaging demonstrated an SSDH extending from L3 to L4 with a significantly decreased platelet count (30.0 × 10⁹/L). The pain was gradually relieved after 2 weeks of conservative treatment, and no neurological deficit occurred during the 1-year follow-up. Brain surgery may increase the risk of postoperative SSDH in patients with ITP. Clinicians planning brain surgery must conduct a rigorous assessment through detailed physical examination, laboratory tests, and medical history records and maintain perioperative platelet counts within the normal range to prevent various risks associated with spinal cord compression.

Performance of a new portable near-infrared spectroscopy device for detection of traumatic intracranial hematoma

INTRODUCTION

We report results of a newly developed portable near-infrared spectroscopy (NIRS) based point-of-care device CEREBO® to detect traumatic intracranial hematoma (TICH).

MATERIALS AND METHODS

Patients with alleged history of head injury visiting emergency room were enrolled. They were examined consecutively for the presence of TICH using CEREBO® and computed tomography (CT) scans.

RESULTS

A total of 158 participants and 944 lobes were scanned, and 18% of lobes were found to have TICH on imaging with computed tomography of the head. 33.9% of the lobes could not be scanned due to scalp lacerations. The mean depth of hematoma was 0.8 (SD 0.5) cm and the mean volume of the hematoma was 7.8 (11.3) cc. The overall sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) of CEREBO® to classify subjects as hemorrhagic or non-hemorrhagic were 96% (CI 90 - 99%), 85% (CI 73 - 93%), 92% (CI 86 - 96%), 91% (CI 84 - 96%) and 93% (CI 82 - 98%) whereas to classify the lobes as hemorrhagic and non-hemorrhagic, the sensitivity, specificity, accuracy, PPV and NPV were 93% (CI 88 - 96%), 90% (CI 87 - 92%), 90% (CI 88 - 92%), 66% (CI 61 - 73%), and 98% (CI 97 - 99%) respectively. The sensitivity was highest at 100% (CI 92 - 100%) for the detection of extradural and subdural hematoma. The sensitivity for detecting intracranial hematoma including epidural, subdural, intracerebral and subarachnoid hematomas, of more than 2 cc was 97% (CI 93 - 99%) and the NPV was 100% (CI 99 - 100%). The sensitivity dropped for hematomas less than 2cc in volume to 84% (CI 71 - 92%) and the NPV was 99% (CI 98 - 99%). The sensitivity to detect bilateral hematomas was 94% (CI 74 - 99%).

CONCLUSION

The performance of currently tested NIRS device for detection of TICH was good and can be considered for triaging a patient requiring a CT scan of the head after injury. The NIRS device can efficiently detect traumatic unilateral hematomas as well as those bilateral hematomas where the volumetric difference is greater than 2cc.

Acute Subdural Hematoma Associated with Aneurysmal Rupture: A Case Series and Review of Literature

BACKGROUND

Ruptured cerebral aneurysms represent a neurosurgical emergency with characteristic clinical presentation and imaging findings. However, atypical presentations may occur in association with acute subdural hematomas (SDHs).

METHODS

A retrospective review was conducted at our institution between 2013 and 2021 to identify patients with aneurysmal rupture presenting with SDH. Cases were reviewed for clinical presentation, imaging findings, management, and outcome.

RESULTS

A total of 8 patients were included in this review with an average age of 48.5 years. Six patients were women. The average Glasgow coma scale upon arrival was 6.3, and the Hunt-Hess average grade was 4.6. Aneurysm locations included posterior communicating artery (n = 3), anterior communicating artery (n = 2), middle cerebral artery (n = 2), and internal carotid artery terminus (n = 1). The size of aneurysm varied between 3 and 11 mm. Seven patients required surgical intervention, either craniotomy or craniectomy for hematoma evacuation, and aneurysms were treated by coiling (n = 2) or clipping (n = 6).

CONCLUSIONS

Ruptured aneurysms may present with SDH with or without significant subarachnoid hemorrhage. This illustrative case series highlights this challenging presentation and the importance of early recognition and appropriate management.

Comparison of clinical characteristics with spontaneous intracranial hypotension complicated with subdural hematoma between surgical treatment and non-surgical treatment

OBJECTIVES

The aim of this current study was to analyze the possible surgical predictive factors about spontaneous intracranial hypotension (SIH) complicated with subdural hematoma (SDH).

METHODS

178 patients diagnosed with both SIH and SDH were retrospectively reviewed. All the participants were divided into as EBP group (BPG) and surgical treatment group (STG). The demographic, clinical manifestations, radiographic and treatment data of the two groups were collected and compared by the electrical medical history system.

RESULTS

The male patients accounted for the majority in the STG (77.88 %), which was significantly larger than those in the BPG(p = 0.004). Patients who regularly smoked and drunk alcohol in the STG group were significantly greater than those in the BPG group (p_(smoking)= 0.049, p_(drinking)= 0.014). The headache occurring in the temporal position in the STG accounted for 44.44 % which was significantly greater than those in the BPG (25.17 %, p = 0.040). The durations days of symptoms were 54.85 ± 34.78 and 33.72 ± 34.97 in the STG and BPG respectively (p = 0.005). The midline shift degree in the STG was also significantly greater than that in the BPG (p = 0.001). The largest hematoma depth in the STG was significantly greater than that in the BPG (p = 0.000). The frequency of blood patch in the STG was significantly greater than that in the BPG(p = 0022).

CONCLUSION

Male, unhealthy living habits, temporal headache, duration of headache, midline shift, hematoma depth and blood patch frequency were possible related factors with the poor outcome of blood patch and surgical treatment.

Acute Traumatic Subdural Hematoma and Anticoagulation Risk

BACKGROUND

Anticoagulation is used to prevent thromboembolic events. It is a common practice to hold anticoagulation in the first few days following a traumatic brain injury (TBI) with intracranial hemorrhage. However, traumatic subdural hematomas (SDH) are prone to re-hemorrhage long after the trauma. Data are scarce in the literature on the best timing to resume anticoagulation following a TBI.

METHODS

Review of 95 consecutive patients admitted to a level 1 trauma center with a diagnosis of traumatic SDH and requiring anticoagulation. The reasons for anticoagulation, the amount of time without anticoagulation, CT characteristics, and the incidence of thromboembolic events or SDH re-hemorrhage were collected.

RESULTS

41.3% used anticoagulation for coronary artery disease and peripheral vascular disease, 24% for atrial fibrillation, 12% for cardiac valve replacement, and 12% for venous thromboembolic events. Anticoagulation was held a median of 67 days. For most patients (82.1%), anticoagulation was re-introduced once the SDH had completely resolved. For 17.9%, anticoagulation was restarted while the SDH had not completely resolved. One (1.1%) patient suffered from an atrial clot while anticoagulation was held. For those with residual SDH, 41.2% suffered from a SDH re-hemorrhage and 17.6% required surgery. The risk of re-hemorrhage climbed to 62.5% if the SDH remnant was large.

CONCLUSION

Anticoagulation while there is a residual SDH was associated with a significant risk of re-hemorrhage. This risk should be weighed against the risk of holding anticoagulation.

Meningioma Presenting with Spontaneous Venous Intraparenchymal Hemorrhage

A 65-year-old woman with a known right-sided, dural-based lesion and metastatic pancreatic neuroendocrine tumor presented with multiple days of progressive lethargy and left-sided weakness culminating with obtundation and dilated pupils. Computed tomography demonstrated an acute right convexity subdural hematoma and a frontotemporal intraparenchymal hemorrhage with 1.3 cm of midline shift, uncal herniation, and an increase in size of now a hemorrhagic dural-based lesion. She underwent emergency hemicraniectomy for evacuation of subdural hematoma and resection of hemorrhagic meningioma with excellent postoperative result including improvement in midline shift and gross total resection of lesion. Pathology was consistent with a World Health Organization grade II meningioma with a chordoid component. She underwent adjuvant stereotactic radiosurgery and cranioplasty and made a full neurologic recovery. Identification of hemorrhagic meningioma as the underlying pathology causing multicompartmental hemorrhage is crucial. We recommend single-stage decompression with extraaxial clot evacuation and resection of the meningioma when feasible.

Optic nerve sheath diameter as a quantitative parameter associated with the outcome in patients with traumatic brain injury undergoing hematoma removal

PURPOSE

To determine the association between optic nerve sheath diameter (ONSD) and outcome in patients with traumatic brain injury (TBI) who undergo hematoma removal (HR).

METHODS

This study was a retrospective analysis of data from a single center between 2016 and 2021. Adult patients with TBI who underwent HR within 24 h after admission were included in this study. Preoperative and postoperative ONSD of the surgical side and the mean ONSD of both sides were measured for analysis. The primary outcome was mortality at 30 days. Receiver operating characteristic curve analysis was performed to calculate the area under the curve (AUC) and 95% confidence interval (CI) for 30 days mortality.

RESULTS

Sixty-one patients were enrolled in the study. Among them, 48 (78.7%) survived for 30 days after admission. The AUC and 95% CI of the postoperative mean ONSD on both sides and postoperative/preoperative mean of the ONSD ratio on both sides were 0.884 [0.734-0.955] and 0.875 [0.751-0.942], respectively. The postoperative mean of both ONSDs of 6.0 mm had high accuracy as a cut-off value with a sensitivity of 85%, specificity of 83%, positive likelihood ratio (LR) of 5.0, and negative LR- of 0.18.

CONCLUSION

This study demonstrated that postoperative ONSD and the postoperative/preoperative ONSD ratio were associated with postoperative outcome in patients with TBI who underwent HR.

Characterization of subdural collections in initial neuroimaging of abusive head trauma: Implications for forensic age diagnostics and clinical decision-making

PURPOSE

Subdural collections (SDCs) represent a key finding in abusive head trauma (AHT), a serious form of child physical abuse. Common SDC entities in this context are subdural hematoma (SDH), subdural hygroma (SDHy), subdural hematohygroma (SDHHy), and chronic subdural hematoma (cSDH). The present study examines the prevalence of the different SDC entities and investigates the influence of the SDC diagnosis on the forensic age estimation of the injury.

METHODS

In this retrospective multi-center study from three German university hospitals of a 10-year period, the initial neuroimaging material (CT or MRI) of 56 children (36 males, 20 females; age median 3.9 months) with medico-legally well-documented AHT was analyzed. SDCs were characterized by determining presence, location, extension, and visual appearance, by assigning to one of the five entities, and by categorizing with three different classification systems, one of which represents a novel system based on focality and Mixed Appearance Pattern and especially developed for children with AHT. The data were correlated with demographic and clinical data. By means of court files, AHT cases were also sub-divided into confession (n = 14) and non-confession cases (n = 42) and then compared.

RESULTS

Most cases showed a multifocal presence of SDCs (96.4%) and the presence of a Mixed Appearance Pattern (82.1%). The most common SDC entity was the heterogeneous variant of the SDHHy (66.1%). The cSDH occurred infrequently only (3.6%). Our novel classification system illustrates that unifocal SDCs rarely occur in AHT, and that more complex SDC patterns are common. In nearly all cases (94.6%), additional signs of recently caused brain injury were present beside the SDCs. Comparison between confession and non-confession groups did not reveal any significant differences, indicating that the diagnostic criteria of AHT are robust.

CONCLUSIONS

Although precise dating of SDCs based on initial neuroimaging alone remains unrealistic, the exact diagnosis of the SDC entity provide an important basis for differentiation between acute trauma and chronic post-traumatic state. Therefore, especially the confirmation or exclusion of subdural neomembranes, that define the cSDH, should be considered indispensable.

Outcomes of Particle versus Liquid Embolic Materials Used in Middle Meningeal Artery Embolization for the Treatment of Chronic Subdural Hematoma

BACKGROUND

Early evidence suggests that middle meningeal artery (MMA) embolization is an efficacious minimally invasive neuroendovascular technique for the management of chronic subdural hematoma (cSDH). Particle and liquid embolic materials are commonly used to embolize the MMA; however, studies comparing the safety and outcomes between these 2 materials are limited.

METHODS

Patients ≥18 years old who had MMA embolization for cSDH between July 15, 2020 and May 1, 2022 were retrospectively identified from a single-center database. The primary safety, radiation dosage, fluoroscopy time, and radiographic and clinical outcomes were compared between particle and liquid embolization.

RESULTS

In a cohort of 116, 48 (41.38%) were treated with liquid embolic material and 68 (58.62%) were treated with particle. The median age of the cohort was 73 years in the particle group and 73.5 years in the liquid embolic group. There was no significant difference in radiation dose or duration among both groups. There was no reported mortality associated with the procedure. One patient experienced nondisabling ischemic stroke in the particle group. Based on imaging follow-up, 3 patients in the particle group and 1 in the liquid embolic group had asymptomatic recurrence. One patient in each group had symptomatic recurrence requiring hematoma evacuation. The index median size of hematoma was 12 mm in the particle group and 11 mm in the liquid embolic group. At approximately 1 month follow-up, the median size of hematoma reduced to 6 mm in both groups.

CONCLUSIONS

Our series shows that liquid embolic and particle embolization are equally safe and effective among patients undergoing MMA embolization for management of cSDH.

An investigation of the effect of brain atrophy on brain injury in multiple sclerosis

Multiple sclerosis (MS) is a disease of the central nervous system (CNS) that affects the brain and spinal cord. It is estimated that the average prevalence of MS is 35.9 cases per 100,000 and a total of 2.8 million people worldwide have MS. Brain atrophy is usually seen in the early stages of MS, and its progress is faster than healthy people. The present study was a numerical study that uses the Fluid-structure interaction (FSI) model to investigate the effect of brain atrophy on brain injury in MS. Firstly, a healthy model was constructed from MRI images and validated by experimental data. Then three models with different degrees of brain atrophy, which showed the rate of brain atrophy in different years in MS patients, were developed to model the brain atrophy in MS. The models were subjected to two different types of impact conditions. Type I, which only produced a translational motion and the HIC value of 744, was applied to each model. Type II produced both translational and rotational motion. In this type of impact, the experimental kinematics, with peaks of 450 g for the translational acceleration and 26.2 krad/s2 for the rotational acceleration, were applied to the nodes that located in the center of gravity of the head models and the results were extracted from each one. According to the results of impact type I, the pressure of the frontal lobe of the brain is 149,647 Pa in the health model and 137,690 Pa in the model with severe atrophy.

A rare presentation of extra-axial supratentorial ependymoma with subdural hematoma mimicking a parasagittal meningioma

Introduction

Primary extra-axial ependymomas, though rare, the majority of such lesions are identified as WHO grade III ependymomas. These ependymomas may mimick a meningioma on radiological investigations which can be confirmed by histopathology.

Research Question

We show in this case report a rare presentation of extra-axial supratentorial ependymoma with concomitant subdural hematoma mimicking a parasagittal meningioma.

Material and Methods

A 59 years lady with no known comorbidities presented with weakness of right half of body and decreased speech for 2 days. She was aphasic. Contrast MRI brain revealed an extra-axial dural-based homogenously enhancing lesion in the left anterior 1/3^rd parasagittal area with left frontotemporoparietal chronic subdural hematoma. With a provisional diagnosis of meningioma, the patient was subjected to bifrontal open-book craniotomy with gross total excision of lesion with periosteal graft duraplasty and acrylic cranioplasty. Left sided frontotemporal subacute SDH with thin greenish yellow membrane was present. In post operative period, patient quickly became E4V5M6 with power of 4/5 in the right half of body which was same as compared to the preoperative period.

Results

The biopsy of the mass, however, revealed features suggestive of extra-axial supratentorial ependymoma (WHO Grade III). Immunohistochemistry supported the diagnosis of supratentorial ependymoma, NOS. The patient was then referred for further chemoradiation.

Discussion and Conclusion

We report the first case of extra-axial supratentorial ependymoma mimicking a parasagittal meningioma occurring with adjacent subdural hematoma. Clinical and imaging background along with a complete pathological examination with immunohistochemical study is essential to confirm the diagnosis of rare brain tumours.

Warfarin-Associated Fetal Subdural Hematoma Causing Severe Neurodevelopmental Delay: A Case Report

Fetal subdural hematoma is an antenatal finding associated with significant morbidity and mortality. It can occur due to maternal or fetal risk factors, and its management varies based on the underlying cause and the anticipated long-term outcomes. We present a case of warfarin-associated fetal subdural hematoma resulting in a live birth and severe neurodevelopmental delay by 10 years of age. In conclusion, counseling regarding the risk of fetal intracranial hemorrhage and the potential neurodevelopmental delay is essential in women who require anticoagulation with warfarin. In addition, close antenatal follow-up with fetal sonography and strict INR monitoring are essential preventative measures.

Newborn with severe supratentorial subdural hematoma due to laceration of the tentorium cerebelli

PURPOSE

A rare case of a newborn girl born by a normal vaginal delivery who developed a severe supratentorial subdural hematoma due to a laceration in the tentorium cerebelli is presented.

METHODS AND RESULTS

The girl, born by normal vaginal delivery at 39 weeks and 4 days of gestation, showed an intermittent decrease in oxygen saturation and bulging of the anterior fontanelle. Computed tomography (CT) and magnetic resonance imaging (MRI) showed a subdural hematoma centered in the left occipital region with a midline shift. Hematoma evacuation with craniotomy was performed, and the source of bleeding was a laceration of the tentorium cerebelli.

CONCLUSION

Severe supratentorial subdural hematomas can occur due to laceration of the tentorium cerebelli even in a normal vaginal delivery.

Different Approaches in Skull Base Surgery Carry Risks for Different Types of Complications

Complications are not uncommon in the complex field of skull base surgery. The intrinsic relationship of lesions in this region to important neurovascular structures, dura mater, and bone may lead to significant morbidity and mortality. The evolution of endoscopic endonasal surgery has had a significant impact on this field as a less invasive option for treatment of selected lesions, but major morbidity may still occur; moreover, endoscopic approaches have been associated with higher rates of some specific complications, such as cerebrospinal fluid leaks. Based on a presented case report, the authors discuss the management of various complications associated with different approaches for resection of skull base malignancies, including epidural and intradural pneumocephalus, subdural hematoma, and subdural empyema. Important lessons learned by the senior author throughout more than 30 years of his skull base surgery practice are highlighted. The inherent risk of complications in skull base surgery emphasizes the importance of their avoidance, prevention, and learning from one's unfavorable experience so as not to repeat them.

An infantile traumatic brain injury with a bright tree appearance detected before the late seizure

INDRODUCTION

Infantile traumatic brain injury (TBI) rarely follows a biphasic clinical course and exhibits a bright tree appearance (BTA) on magnetic resonance imaging (MRI). This is termed infantile traumatic brain injury with a biphasic clinical course and late reduced diffusion (TBIRD). TBIRD has clinical features similar to those of acute encephalopathy with biphasic seizures and late reduced diffusion (AESD). It remains to be clarified which patients with infantile TBI will develop TBIRD and the prevention and treatment of TBIRD.

CASE AND REVIEW

We report a case of TBIRD that exhibited BTA 1 day before the late seizure and review 12 cases of TBIRD. All patients developed a subdural hematoma (SDH), were younger than 2 years, and presented with a biphasic phase within 3-6 days. The median interval between BTA and TBI was 5 days. Of the 5 cases examined with MRI before the biphasic phase, only our case was detected with BTA 4 days after TBI.

CONCLUSION

Predicting the biphasic clinical course may be possible by examining MRI after TBI in patients under 2 years of age who develop SDH with unconsciousness, seizure, or hemiplegia, and these patients should be strictly followed up for 1 week.