Factors associated with success of conservative therapy in chronic subdural hematoma: a single-center retrospective analysis

INTRODUCTION

Conservative therapy is a viable option for patients with chronic subdural hematoma (cSDH) who express no, or only mild symptoms. It is not clear which factors are associated with success of conservative therapy. This study aims to determine conservative therapy's success rate and to identify features possibly associated with success.

METHODS

A monocenter retrospective cohort study, including cSDH patients treated conservatively (wait-and-watch) from 2012 to 2022, was performed. The primary outcome was success of conservative therapy, defined as 'no crossover to surgery' during the follow-up period. Secondary outcomes were (1) factors associated with success, analyzed with univariate and multivariable logistic regression analyses, (2) 30-day mortality (3) time to crossover and (4) reasons for crossover.

RESULTS

We included 159 patients. Conservative therapy was successful in 96 (60%) patients. Hematoma volume (OR 0.79, 95% CI 0.69-0.92) and hypodense hematoma type (OR 3.57, 95% 1.38-9.23) were associated with success. Thirty-day mortality rate was 5% and the median duration between diagnosis and surgery was 19 days (IQR 8-39). Clinical deterioration was the most frequent reason for crossover (in 61/63 patients, 97%) and was accompanied by radiological hematoma progression in 42 patients (67%).

CONCLUSION

In this selected group of patients, conservative therapy was successful in 60%. Smaller hematoma volume and hypodense hematoma type were associated with success. As time until crossover was approximately three weeks, deploying conservative therapy as primary treatment seems safe and could be rewarding as surgical complications can be avoided. Improvement in patient selection in future cohorts remains warranted.

Development of the SAFETEA Scores for Predicting Risks of Complications of Preventive Endovascular or Microneurosurgical Intracranial Aneurysm Occlusion

BACKGROUND AND OBJECTIVES

Preventive unruptured intracranial aneurysm (UIA) occlusion can reduce the risk of subarachnoid hemorrhage, but both endovascular and microneurosurgical treatment carry a risk of serious complications. To improve individualized management decisions, we developed risk scores for complications of endovascular and microneurosurgical treatment based on easily retrievable patient, aneurysm, and treatment characteristics.

METHODS

For this multicenter cohort study, we combined individual patient data from patients with UIA aged 18 years or older undergoing preventive endovascular treatment (standard, balloon-assisted or stent-assisted coiling, Woven EndoBridge-device, or flow-diverting stent) or microneurosurgical clipping at one of the 10 participating centers from 3 continents between 2000 and 2018. The primary outcome was death from any cause or clinical deterioration from neurologic complications ≤30 days. We selected predictors based on previous knowledge about relevant risk factors and predictor performance and studied the association between predictors and complications with logistic regression. We assessed model performance with calibration plots and concordance (c) statistics.

RESULTS

Of the 1,282 included patients, 94 (7.3%) had neurologic symptoms that resolved <30 days, 140 (10.9%) had persisting neurologic symptoms, and 6 died (0.5%). At 30 days, 52 patients (4.1%) were dead or dependent. Predictors of procedural complications were size of aneurysm, aneurysm location, familial subarachnoid hemorrhage, earlier atherosclerotic disease, treatment volume, endovascular modality (for endovascular treatment) or extra aneurysm configuration factors (for microneurosurgical treatment, branching artery from aneurysm neck or unfavorable dome-to-neck ratio), and age (acronym: SAFETEA). For endovascular treatment (n = 752), the c-statistic was 0.72 (95% CI 0.67-0.77) and the absolute complication risk ranged from 3.2% (95% CI 1.6%-14.9%; ≤1 point) to 33.1% (95% CI 25.4%-41.5%; ≥6 points). For microneurosurgical treatment (n = 530), the c-statistic was 0.72 (95% CI 0.67-0.77) and the complication risk ranged from 4.9% (95% CI 1.5%-14.9%; ≤1 point) to 49.9% (95% CI 39.4%-60.6%; ≥6 points).

DISCUSSION

The SAFETEA risk scores for endovascular and microneurosurgical treatment are based on 7 easily retrievable risk factors to predict the absolute risk of procedural complications in patients with UIAs. The scores need external validation before the predicted risks can be properly used to support decision-making in clinical practice.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that SAFETEA scores predict the risk of procedural complications after endovascular and microneurosurgical treatment of unruptured intracranial aneurysms.

PATH-48. THE DNA METHYLATION LANDSCAPE OF CORE AND PERIPHERAL DIFFUSE GLIOMA REGIONS SHOWS LITTLE SPATIAL SUBTYPE HETEROGENEITY AFTER CONSIDERING TUMOR PURITY

While diffuse gliomas are notorious for their histopathological, genetic and transcriptional spatial heterogeneity, little is known about their epigenetic spatial heterogeneity. The result of spatial (epi)genetic analysis is strongly influenced by the proportion of cancer cells in a sample, so called tumor purity. However, a gold standard for assessment of tumor purity is lacking. We set out to analyze tumor purity using different measurement modalities and explore tumor purity-corrected DNA methylation spatial heterogeneity in glioma. DNA methylation(-derived), quantitative histological and radiological measurements of tumor purity, as well as DNA methylation profiles, were analyzed in 133 image-guided multi-sector stereotactic biopsy samples of 16 patients with newly diagnosed glioma. These biopsies were acquired in regions with and without abnormalities on MRI. Data was validated in two independent populations of respectively 102 multi-region samples in 24 glioma patients and 64 single-region samples from patients without glioma. DNA methylation profiles from The Cancer Genome Atlas and the patients without glioma was used to predict DNA methylation and transcriptional subtype. Consensus measurement of tumor purity estimates (CPE) ranged from 0 to 91% and was most correlated with the DNA methylation measurement of tumor purity. Neuropathological qualitative assessment of tumor presence generally corresponded well with CPE, but occasionally samples reported as ‘histologically normal’ demonstrated tumor purities up to 53%. After filtering specimens with tumor purity less than 50%, DNA methylation subtype showed little spatial heterogeneity, this in contrast to transcriptional subtype. Samples from core and peripheral regions showed similar DNA methylation profiles. Non-purity related intratumoral heterogeneity for promotor methylation of epigenetically regulated genes was minimal, but higher in IDH-wildtype than in IDH-mutant gliomas. In conclusion, after considering DNA methylation-based measurement of tumor purity DNA methylation in diffuse gliomas shows little spatial heterogeneity; incorporating such tumor purity information can further increase the reliability of methylation-profiling-based tumor classification.

MON-458 Radiological Alterations Of The Hypothalamic-pituitary Region After Craniospinal Irradiation For Medulloblastoma During Childhood

Background Hypothalamic-pituitary (HP) dysfunction after craniospinal irradiation (CSI) is frequently observed in childhood brain tumor survivors (CBTS). The risk increases with higher dose and younger age at time of radiation exposure. Whether radiological alterations of the HP-region or alterations in brain volume are predictive of HP dysfunction remains unknown. Aim The aim of this (retrospective) study was to quantify radiological alterations of the HP-region in time in CBTS after CSI and to correlate these alterations to the occurrence of HP dysfunction. Methods Ninety survivors of childhood medulloblastoma (mean age at diagnosis: 8.3 years) from a previously reported nationwide cohort, treated with CSI between 2002-2012, were included. Sixty CBTS (67%) were diagnosed with HP dysfunction during follow-up (FU). All MRI scans were collected from time of diagnosis, post-neurosurgical intervention, post-radiation and 3 and 5 years of FU. Pituitary height (PH) and width (PW) were measured on mid-sagittal images. The pituitary stalk (PS) width was assessed by measuring the ratio of the PS to basilar artery (BA) on axial images on the same plane in the middle of the PS. Volume measurements of the PG (PGV) were performed. Observers were blinded for outcome of HP function. Separate analyses were performed for children < 6 years at time of CSI. All measurements were corrected for age and gender using Z-scores. Statistical analyses were performed by SPSS (General Linear Model repeated measures with Bonferroni correction). Results Mean PH (p<0.01, 95% CI [0.25, 1.27], PW (p<0.01, 95% CI [0.85-2.32], width of the PS (p<0.01, 95% CI [0.38-3.0] and PGV (p<0.05, 95% CI [0.12-1.29] declined during FU. No correlation was observed between radiological alterations in time and the presence of HP dysfunction. On a marginal trend level, an interaction effect was seen for PS/BA ratio and the presence of HP dysfunction (p= 0.097, F= 2.44). HP dysfunction occurred more frequently in CBTS treated with CSI < 6 years (71% vs 58%). Radiological alterations in this age group could also not be related to occurrence of HP dysfunction. Conclusion When compared to age and gender reference values, CBTS treated with CSI show radiological alterations of the HP region in time. Exposure to cranial irradiation in childhood seems to have a negative effect on PH, PW, width of PS and PGV. However, these effects cannot be related to the development of HP dysfunction or age at time of CRT. Prospective studies are needed to confirm these results, with systematic evaluation of the HP function in time.