Recurrent hiccups associated with ipsilateral intracerebral hemorrhage and chronic subdural hematoma with immediate resolutions after evacuations

A 74-year-old man presented with persistent hiccups and headache persisting for 2 days. An anticoagulant was administered for his coronary heart disease. Cranial computed tomography (CT) revealed an intracerebral hemorrhage (ICH) located in the right occipital lobe, without any abnormal findings around the brainstem. The patient underwent endoscopic hematoma evacuation via a burr hole, resulting in immediate resolution of hiccups. Following an uneventful postoperative course, the patient experienced recurrent hiccups on the 47th day postsurgery. A subsequent CT scan taken on the 50th day revealed a compressive chronic subdural hematoma (CSDH) situated in the right frontoparietal convexity. The patient underwent burr-hole irrigation, leading to prompt cessation of the hiccups. Persistent hiccup should be recognized as potential manifestation of supratentorial lesions, including ICH or CSDH. Surgical evacuation of such lesions can rapidly alleviate hiccups associated with these pathologies.

Comparison of adjunctive middle meningeal artery embolization using embosphere particles versus surgical drainage alone for the treatment of chronic subdural hematoma: A prospective study

BACKGROUND

Middle meningeal artery embolization (MMAE) has emerged as a primary and adjunctive therapy for chronic subdural hematoma (CSDH) in addition to conventional treatment. However, there is a scarcity of data that explicitly compares the effectiveness of adjunctive MMAE to surgical drainage alone (SDA), as well as the use of Embosphere particles. The objective of this study was to assess the safety and efficacy of adjunctive MMAE in the treatment of symptomatic CSDH compared to SDA.

METHODS

This prospective study included 43 patients with 52 CSDH sides, treated at a single institution between 2022 and 2023. The primary outcome was postoperative hematoma volume at 14, 30, 90, and 180 days after surgical drainage, which was analyzed using the generalized estimating equation. The secondary outcomes were the complications and recurrence/reoperation rate. Adjunctive MMAE was performed within 7 days following the surgery, utilizing Embosphere as the embolic material.

RESULTS

The patients were assigned to either the adjunctive MMAE group (n = 20, 26 CSDH sides) or the SDA group (n = 23, 26 CSDH sides). The adjunctive MMAE group demonstrated a more significant reduction in hematoma volume (p = 0.007) and maximal hematoma thickness (p = 0.016) at all follow-up intervals. A trend towards lower recurrence and reoperation rates was observed with adjunctive MMAE; particularly, none of the patients in the adjunctive MMAE group experienced a recurrence of CSDH, compared to 19.2 % in the SDA group (p = 0.051). One procedural-related complication (3.8 %) in the adjunctive MMAE group.

CONCLUSION

Our results suggested that adjunctive MMAE, compared to SDA, may enhance hematoma resolution and reduce the need for reoperation due to recurrence.

The pharmacological landscape of chronic subdural hematoma: a systematic review and network meta-analysis of randomized and non-randomized controlled studies

Background

There are various treatment modalities for chronic subdural hematoma (CSDH) and there is extensive debate surrounding pharmaceutical interventions. There is no consensus regarding the relative efficacy and safety of multiple treatment modalities. This study aims to investigate this issue and offer potential clinical recommendations.

Methods

We searched PubMed, Web of Science, Embase and the Cochrane Library from January 2000 to May 2023 to identify randomized and nonrandomized controlled studies reporting one or more outcomes associated with the pharmacologic management of CSDH. The primary outcomes of interest included recurrence, favorable prognosis and adverse events, while the secondary outcomes included a reduction in hematoma volume and mortality. Pooled estimates, credible intervals and odds ratios were calculated for all outcomes using a fixed effects model. Confidence in network meta-analysis judgments were employed to stratify the evidential quality. This study was registered with PROSPERO: CRD42023406599.

Results

The search strategy yielded 656 references; ultimately, 36 studies involving 8082 patients fulfilled our predefined inclusion criteria. The findings suggested that statins + glucocorticoids (GCs) ranked highest for preventing recurrence, improving prognosis and facilitating hematoma absorption. Tranexamic acid ranked second highest for preventing recurrence. Statins were found to be the preferred drug intervention for decreasing mortality and preventing adverse events. Antithrombotic agents ranked lowest in terms of decreasing mortality and improving prognosis.

Conclusions

Our findings indicate that statins + GCs may be the most effective treatment modality for preventing recurrence, improving patient prognosis and facilitating hematoma absorption. In terms of reducing mortality and preventing adverse events, statins may be superior to other pharmacological interventions. Routine use of GCs is not suggested for patients with CSDH. Further prospective research is needed to directly compare the efficacy and superiority of various pharmaceutical interventions targeting CSDH to reinforce and validate our findings.

Middle meningeal artery embolization versus conventional management for patients with chronic subdural hematoma: An umbrella review

BACKGROUND AND OBJECTIVES

Conventional surgical modalities, including twist drill craniotomy, burr hole evacuation, and craniotomy, are the standard surgical interventions for chronic subdural hematomas (cSDH). More recently, treatment of cSDH with middle meningeal artery embolization (MMAE) is being explored. The comparative effectiveness of MMAE versus conventional surgical modalities remains controversial. The objective of this study is to analyze various postoperative outcomes in an umbrella review of existing meta-analysis comparing MMAE and conventional management in patients with cSDH.

METHODS

A systematic literature search was executed with defined criteria across PubMed, Scopus, and Web of Science databases. Data was analyzed utilizing the metaumbrella R package, employing equivalent Hedges' g values. The quality assessment of each meta-analysis was carried out using AMSTAR2, assigning scores within the range of 0-11. The credibility of the evidence was determined by applying the Ioannidis criteria.

RESULTS

This umbrella review study included five meta-analyses. Upon pooling the meta-analyses, MMAE was associated with fewer reoperations and recurrence, supported by a weak level of evidence (class IV). Conversely, findings related to other postoperative outcomes did not reach statistical significance.

CONCLUSION

Our umbrella review offers a comprehensive summary investigating MMAE and conventional management for the treatment of cSDH. MMAE had fewer reoperations and recurrence, but they were classified as being of weak significance. These findings underscore insufficient evidence within the existing literature, emphasizing the imperative need for additional research in this area.

Prediction model for poor short-term prognosis in patients with chronic subdural hematoma after burr hole drainage: a retrospective cohort study

Chronic subdural hematoma (CSDH) is a common condition in neurosurgery. With an aging population, there is increasing attention on the prognosis of patients following surgical intervention. We developed a postoperative short-term prognostic prediction model using preoperative clinical indicators, aiming to assist in perioperative medical decision-making and management. The dataset was randomly divided into training and validation cohorts. An mRS score greater than 2 one month after discharge was considered indicative of a poor prognosis. In the training cohort, the least absolute shrinkage and selection operator (LASSO) regression analysis was used for multivariate analysis to identify independent risk factors and construct a prediction nomogram for poor prognosis one month after discharge. The performance of the nomogram was assessed using the Receiver Operating Characteristic (ROC) curve and calibration curve. A Decision Curve Analysis (DCA) was also conducted to determine the net benefit threshold of the prediction model. Among the 505 participants, 18.8% (95/505) had a poor prognosis one month after discharge. The baseline characteristics did not significantly differ between the training cohort and the validation cohort. LASSO regression analysis in the training cohort reduced the predictors to four potential factors. Further multivariate logistic analyses in the training cohort identified four independent predictors: age, admission Glasgow Coma Scale (GCS) score, hemiparesis, and hemoglobin count. These predictors were incorporated into the nomogram prediction model. Internal validation using ROC analysis, calibration curves, and other methods demonstrated a strong correlation between the observed and predicted likelihood of poor prognosis one month after discharge. The visualized nomogram prediction model we developed for short-term postoperative prognosis of chronic subdural hematoma after burr hole drainage aids in predicting short-term outcomes and guiding clinical treatment decisions. Further external validation is needed in the future to confirm its effectiveness.

Endovascular treatment of chronic subdural hematoma in a dual-trained neurosurgical unit: Results and proposal of a randomized controlled trial protocol

INTRODUCTION

Chronic subdural hematoma (cSDH) is a prevalent neurosurgical condition with an increasing incidence due to the rising life expectancy and the widespread use of anticoagulant and antiplatelet therapies. Insights into the inflammatory origins of cSDH led to the exploration of Middle Meningeal Artery (MMA) embolization as a therapeutic strategy. In recent years the endovascular treatment of MMA has gained momentum. Herein we present the initial experience of a dual trained neurovascular unit implementing this therapeutic technique.

METHODS

This single-center, prospective pilot study aimed to evaluate the feasibility, safety, and efficacy of MMA embolization in the treatment of cSDH. Following ethical approval and informed consent, demographic, clinical, and radiological data were collected. Patients requiring emergent surgical treatment were excluded. The study focused on assessing clinical outcomes, including the Modified Rankin Score (mRS) and volumetric analysis of cSDH, before and after embolization.

RESULTS

Fifteen patients underwent MMA embolization, with a predominance of males (80%) and a mean age of 72.4 years. The most common presenting symptom was headache (53.3%). The average hospital stay was 3.9 days. Various embolization techniques were employed, with DMSO-EVOH being the most frequent. All procedures were successfully conducted without complications. Although not statistically significant, trends suggested better outcomes in patients with homogeneous cSDH on the CT scan, displaying the cotton wool sign on angiography and treated with EVOH-DMSO.

CONCLUSION

MMA embolization for cSDH demonstrates promise as a safe and effective treatment, potentially reducing the need for surgical intervention and recurrence rates. This study lays the groundwork for a larger, randomized controlled trial which protocol is herein presented.

Failure Rates of Conservative Management of Minimally Symptomatic Chronic Subdural Hematoma: A Systematic Review and Meta-Analysis

BACKGROUND

Conservative treatments for minimally symptomatic chronic subdural hematoma (cSDH) are debated, with surgery as the primary option.

OBJECTIVE

To assess failure rates of a conservative approach for management of cSDH.

METHODS

We searched PubMed, SCOPUS, Web of Science, and ClinicalTrials.gov for studies on conservative management of cSDH and analyzed the data using R (version 4.1.2).

RESULTS

A total of 35 studies including 2095 patients were analyzed: 950 (45%) of the patients were in the observation group, 671 (32%) in the corticosteroid group, 355 (17%) in the atorvastatin group, 43 (2%) in the mannitol group, 52 (2.5%) in the tranexamic acid group, and 24 (1.1%) in the etizolam group. Our pooled analysis showed that 19.82% of patients required rescue surgery (95% confidence interval [CI]: 12.98% to 26.66%, P < 0.0001). The overall pooled risk ratio (RR) for the effect of interventions on the need for rescue surgery was 0.2424 (95% CI: 0.1577 to 0.3725, Iˆ2 = 90.5%, P < 0.0001). Subgroup analysis showed varied effects: observation group (RR = 0.3482, 95% CI: 0.1045 to 1.1609, Iˆ2 = 94.0%), corticosteroids (RR = 0.2988, 95% CI: 0.1671 to 0.5344, Iˆ2 = 90.8%), atorvastatin (RR = 0.1609, 95% CI: 0.0985 to 0.2627, Iˆ2 = 53.2%), mannitol (RR = 0.0370, 95% CI: 0.0009 to 1.5244), and tranexamic acid (RR = 0.0585, 95% CI: 0.0026 to 1.2924).

CONCLUSIONS

The rate of rescue surgery in conservatively managed cSDH patients remains high. Corticosteroids or atorvastatin demonstrates some potential benefit in reducing the failure rate but collective effectiveness is unknown.

Transradial approach for middle meningeal artery embolization is a safe alternative to transfemoral approach in patients with chronic subdural hematoma: A single-center retrospective comparative study

BACKGROUND

Transradial approach (TRA) has been increasingly utilized in various neuroendovascular interventions as a safe alternative to the transfemoral approach (TFA). As middle meningeal artery (MMA) embolization emerges as an effective therapy for treating chronic subdural hematomas (cSDH), some studies have explored using TRA. In this study, we compared procedural times and post-operative outcomes between those with TRA and TFA.

METHODS

This is a single-institution retrospective study of patients undergoing MMA embolization for cSDH. The cohort was divided into the TRA and TFA subgroups. Baseline characteristics, procedural times, and immediate outcomes were compared. Univariate analysis was performed.

RESULTS

We performed 62 MMA embolizations for treatment of cSDH, of which 37 (59.7 %) were performed transradial and 25 (40.3 %) were performed transfemoral. Those who underwent TRA were significantly younger than those who had TFA (p = 0.02). For patients who underwent unilateral MMA embolization, those with TRA had significantly shorter duration of procedure compared to the TRF group (p = 0.01). This difference was not observed in the bilateral MMA embolization subgroup. Only three patients had access site complications, and all were in the TFA group. There was no significant difference in length of hospital stay.

CONCLUSION

As MMA embolization for cSDH becomes more prevalent, efforts to optimize the safety and efficacy of the technical aspects become critical. In this study we demonstrate that TRA is a safe and efficient alternative to traditional TFA in those undergoing unilateral MMA embolization.

Chronic subdural hematoma caused by excessive drainage in a patient with ventriculoperitoneal shunt valve breakdown in brain injury: a case report

INTRODUCTION

Chronic subdural hematoma (CSDH) often occurs 3 weeks to 3 months after brain injury, which is mainly caused by bleeding of the bridging vein. For patients with ventriculoperitoneal (V-P) shunt, excessive drainage can also cause CSDH. We present a rare case of CSDH caused by shunt valve breakdown in brain injury.

CASE REPORT

We report a 68-year-old man with V-P shunt for 8 years. He presented with bilateral CSDH with disappearance of lateral ventricles nearly 1 month after a brain injury caused by being hit with a stick. After burr hole drainage (BHD), the patient's symptoms improved and lateral ventricles reappeared, but disappeared rapidly with CSDH recurrence within a short time. We considered the cause to be medium pressure shunt valve breakdown caused by hitting with a stick, which was confirmed by the engineer's test after the operation and excessive drainage of cerebrospinal fluid. BHD replaced the adjustable pressure shunt valve, and the patient recovered.

CONCLUSION

V-P shunt is a common operation in neurosurgery, and postoperative shunt valve breakdown may lead to poor outcome. We report a rare case of CSDH caused by shunt valve breakdown due to excessive external forces, suggesting that patients after V-P shunt should pay attention to the protection of the shunt valve.

Investigation of the Efficacy of Bevacizumab Treatment in An Experimental Rat Model of Chronic Subdural Hematoma

INTRODUCTION

Chronic subdural hematoma (cSDH), a condition that develops over time, is characterized by inflammation, angiogenesis, and membrane development. As the population's average age increases, the incidence of cSDH is expected to grow. While surgery is the primary treatment technique, medicinal therapy options are being explored for high-risk patients. Currently, the most effective therapy combination is dexamethasone (Dex) and atorvastatin (Ato); however, it is associated with an increased risk of mortality. This study explored the effects of bevacizumab (Bev), a vascular endothelial growth factor antagonist, on cSDH.

MATERIALS AND METHODS

Ninety-five rats were divided into four groups (n = 18): sham, control hematoma, Dex-Ato, and Bev. Two separate autologous blood injections into the subdural space were used as the model. Weight was monitored for all rats to assess changes in their overall health. The control group was given i.p. saline, the Dex-Ato treatment was given by gavage, and the Bev treatment was given i.p. On seventh, 14th and 21st days six rats from each group were sacrificed and analyzed, while 23 rats were excluded from the experiment.

RESULTS

The maximum immunological response to cSDH was observed on day 14. Hematoma volume decreased over time in all groups. Dex-Ato and Bev were both found effective, while Dex-Ato caused weight loss.

CONCLUSION

Bev had similar effects to the Dex-Ato group and was well tolerated by rats. Given that cSDH is a disease of the elderly and vulnerable populations, Bev may be a viable alternative that can shed light on the disease's etiology for future research.

Seniority of Surgeon in Chronic Subdural Hematoma Recurrence: A Systematic Review and Meta-analysis

Chronic subdural hematoma (CSDH) is increasingly common, particularly in the older and multimorbid population. Surgical proficiency in management is required in the early years of U.K. neurosurgical training with most cases performed by nonconsultant-grade surgeons. The aim of this systematic review was to examine the effect of surgeon seniority on recurrence for patients with CSDH. Full-text articles comparing surgical treatment for CSDH with a "senior" (consultant/attending level) or "junior" (resident/registrar or similar) lead surgeon were identified. MEDLine and EMBASE databases were searched. The primary outcome of this study was recurrence. Secondary outcomes included postoperative complications and mortality rate. A random effects meta-analysis was performed. The risk of bias was assessed using the National Institute of Health risk of bias toolkit. Five studies were included in the final analysis (n = 941 total patients). Individually, no study identified a significant difference in recurrence rate and postoperative complications between senior and junior neurosurgeons. On meta-analysis, junior-led evacuations had lower recurrence rates on pooled univariable analysis (12.0% vs. 17.9% [odds ratio 0.48, 95% confidence interval 0.29-0.78, I2 = 0%]) (3 studies). Seniority of surgeon was not associated with increased rates of recurrence patients undergoing CSDH surgery. Complexity of operation may be a confounding factor in observed lower recurrence rates with more junior operators.

The efficacy and safety of the internal medication therapy of the triple drugs for chronic subdural hematoma: Retrospective analysis

The recurrence of chronic subdural hematoma (CSDH) after surgical treatment is a severe problem with no effective prevention method. This retrospective study aimed to investigate factors associated with CSDH recurrence after burr hole surgery and hematoma changes on computed tomography before surgery to examine prevention methods for recurrence. A total of 166 hematomas were enrolled in this study, with 139 patients undergoing burr hole surgery for CSDH. Among these patients, 17 (12 %) had recurrence. Propensity score matching was performed based on postoperative drug therapy, including goreisan, carbazochrome sodium sulfonate hydrate, and tranexamic aid, resulting in 39 matched cases in 0-2 and 3 drug therapy groups. The recurrence rates were 18 % for the 0-2-drug therapy group and 3 % for the 3-drug therapy group. Univariate analysis revealed that the use of 0-2 drugs was associated with a higher risk of CSDH recurrence (odds ratio [OR], 8.31; 95 % confidence interval [CI], 0.97-71.17; p = 0.05) compared to the use of 3 drugs. Multivariate regression analysis further confirmed that 0-2 drug therapy after surgery was associated with an increased risk of CSDH recurrence (OR, 11.06; 95 % CI, 1.16-105.4; p = 0.037). Additionally, 36 hematomas were evaluated before surgery, with hematoma changes such as lower density and new trabecular formation detected in 14 CSDHs (39 %). Multivariate regression analysis showed that 3-drug therapy was associated with more cases of hematoma change than 0-2-drug therapy (OR, 13.9; 95 % CI, 1.09-177.65; p = 0.043). The 3-drug therapy was effective in reducing the recurrence of hematoma after burr hole surgery and promoted hematoma thrombosis.

Comparison between the use of subdural and subgaleal drainage in treatment of chronic subdural hematoma

BACKGROUND AND OBJECTIVES

Chronic subdural hematoma (CSDH) is one of the most common pathologies in our daily practice. The standard treatment is the evacuation making a burr-hole and placement of a subdural drainage, which has shown to decrease its recurrence. However, this procedure can entail risks such as parenchymal damage, infection, or the onset of seizures, prompting the consideration of subgaleal drainage as an alternative. Our objective is to compare the use of subdural and subgaleal drainage in a cohort of patients undergoing intervention for CSDH, as well as to analyze the differences in complication rates and recurrence between the two groups.

METHODOLOGY

A retrospective analytical observational study was conducted, analyzing 152 patients diagnosed with CSDH who underwent intervention at our center from January 2020 to April 2022. Patients in whom drainage was not placed were excluded. In all patients, a burr-hole was performed and the type of drainage was chosen by the neurosurgeon.

RESULTS

Out of the 152 patients, subdural drainage was placed in 80 cases (52.63%), while subgaleal drainage was used in 72 cases (47.37%). There were no significant differences in the recurrence rate (30% in the subdural drainage group vs. 20.83% in the subgaleal drainage group; P = .134) or in the complication rate (7.5% in the subdural drainage group vs. 5.5% in the subgaleal drainage group; P = .749).

CONCLUSIONS

Subgaleal drainage shows similar clinical outcomes with a recurrence and complication rate comparable to subdural drainage, suggesting it as a safe and effective alternative to subdural drainage in the treatment of CSDH.

Letter to the editor: "Therapeutic efficacy of drilling drainage combined with intraoperative middle meningeal artery occlusion in the management of chronic subdural hematoma: a clinical study"

This letter addresses the research presented by Sun et al. on the integration of digital subtraction angiography (DSA) with conventional surgical drainage for chronic subdural hematoma (CSDH), focusing on precision in targeting the middle meningeal artery (MMA). The study demonstrates a reduction in hematoma recurrence and drainage tube indwelling times, highlighting the procedural benefits without added complications. The letter suggests further research directions, including the potential for personalized surgical approaches based on MMA anatomy variations, and emphasizes the importance of this technique in enhancing neurosurgical outcomes.

Cost Savings on Inpatient Hospitalization for Middle Meningeal Artery Embolization in the Setting of Increased Case Volume and Low Complications Rate

BACKGROUND

Middle meningeal artery (MMA) embolization for the treatment of chronic subdural hematomas (cSDHs) is becoming increasingly prevalent. It is essential to optimize the safety and cost effectiveness of the postprocedural management. In this study, we examined our cases over time to determine the most appropriate postprocedural destination.

METHODS

This is a retrospective study of patients who underwent MMA embolization for cSDH at our institution. The study cohort was divided into 2 groups based on the year of embolization. Baseline characteristics, postprocedural complications, and length of stay were compared. Patients with shorter intensive care unit (ICU) stay were also compared to those with longer stay. Univariate statistical analysis was performed.

RESULTS

92 MMA embolizations for cSDH have been performed at our institution, of which 36 (39.1%) were done between 2019 and 2022 and 56 (60.9%) after 2023. No patients experienced stroke, cranial nerve palsy, or intraparenchymal hemorrhage after embolization. All but 5 patients were admitted to the ICU postembolization, of which 59 (64.1%) were downgraded after one day. Factors associated with a longer ICU stay included preoperative location (P = 0.002) and need for surgery (P = 0.02). Of those who came from home or nonmonitored bed, 82% were downgraded from the ICU in less than 2 days. The average cost of one night in the ICU, intermediate care, and nonmonitored unit was $3671.75, $2605.22, and $2303.81 respectively.

CONCLUSIONS

MMA embolization for cSDH is a safe procedure with low rate of procedure-related complications. In carefully selected patients, the necessity ICU admission postoperatively should be weighed against better hospital resource utilization.

Transradial versus transfemoral access for middle meningeal artery embolization: Choice of the access route considering delirium in the elderly

Background

Treatment of chronic subdural hematoma (CSDH) with middle meningeal artery embolization (MMAE) is becoming well established. Transradial artery access (TRA) is considered less invasive than transfemoral artery access (TFA) and is increasingly indicated in the field of endovascular therapy. Therefore, this study focused on postoperative delirium and compared access routes.

Methods

This is a single-center and retrospective study. The strategy was to perform MMAE for CSDH with symptomatic recurrence at our hospital. Cases from July 2018 to September 2022, when MMAE was introduced in our hospital, were included in this study. Patients were divided into TRA and TFA groups and were compared descriptively for patient background, procedure duration, and incidence of postoperative delirium.

Results

Twenty-five patients underwent MMAE, of whom 12 (48%) were treated with TRA. The overall median age was 82 years, with no clear differences between the TRA and TFA groups in the presence or absence of preexisting dementia or antithrombotic therapy. Delirium requiring medication tended to be lower in the TRA group: 2/12 (16.7%) in the TRA group versus 6/13 (46.2%) in the TFA group, and the mean procedure time for patients undergoing bilateral MMAE was 151 min (interquartile range [IQR]: 140-173 min) in the TRA group versus 174 min (IQR: 137-205 min) in the TFA group.

Conclusion

TRA was associated with an overall shorter procedure time than TFA. MMAE through TRA tended to have a lower incidence of delirium. MMAE through TRA may be useful in recurrent CSDH with a high elderly population.

ALARA principles in practice: reduced frame and pulse rates for middle meningeal artery embolization

Objective

As the prevalence of neuroendovascular interventions increases, it is critical to mitigate unnecessary radiation for patients, providers, and health care staff. Our group previously demonstrated reduced radiation dose and exposure during diagnostic angiography by reducing the default pulse and frame rates. We applied the same technique for basic neuroendovascular interventions.

Methods

We performed a retrospective review of prospectively acquired data after implementing a quality improvement protocol in which pulse rate and frame rate were reduced from 15 p/s to 7.5 p/s and 7.5 f/s to 4.0 f/s respectively. We studied consecutive, unilateral middle meningeal artery embolizations treated with particles. Total radiation dose, radiation per angiographic run, total radiation exposure, and exposure per run were calculated. Multivariable log-linear regression was performed to account for patient body mass index (BMI), number of angiographic runs, and number of vessels catheterized.

Results

A total of 20 consecutive, unilateral middle meningeal artery embolizations were retrospectively analyzed. The radiation reduction protocol was associated with a 39.2% decrease in the total radiation dose and a 37.1% decrease in radiation dose per run. The protocol was associated with a 41.6% decrease in the total radiation exposure and a 39.5% decrease in exposure per run.

Conclusions

Radiation reduction protocols can be readily applied to neuroendovascular interventions without increasing overall fluoroscopy time and reduce radiation dose and exposure by 39.2% and 41.6% respectively. We strongly encourage all interventionalists to be cognizant of pulse rate and frame rate when performing routine interventions.

Thrombolytic therapy as a superior option: Insights from three cases of acute subdural hematoma following surgery for chronic subdural hematoma

BACKGROUND

Chronic subdural hematoma (cSDH) ranks among the most prevalent neurosurgical conditions, with burr-hole drainage typically yielding favorable prognoses. Nevertheless, perioperative complications may arise, with remote intraparenchymal hemorrhage and subarachnoid hemorrhage occurring infrequently, while acute subdural hematoma (aSDH) remains a relatively common complication post-cSDH removal. The standard treatment for aSDH, typically large craniotomy, substantially elevates surgical risk.

CASE DESCRIPTION

This study presents three cases of postoperative aSDH in elderly patients with cSDH, examining potential causative factors and proposing pertinent strategies. Three elderly patients, admitted urgently due to exacerbating symptoms, underwent preoperative assessment followed by emergency parietal burr-hole drainage. Regrettably, all three patients developed aSDH postoperatively. Various treatment approaches were employed: two cases received thrombolysis with 50,000 units of urokinase, while one case required a large craniotomy. Despite the patients achieving satisfactory outcomes without significant neurological deficits, this study advocates thrombolytic therapy as a potentially superior option for aSDH following cSDH surgery.

CONCLUSION

Urokinase-mediated subdural thrombolysis enhances hematoma clearance rates, suggesting a shift towards minimally invasive treatments to mitigate greater trauma. However, the paucity of evidence necessitates extensive research to validate its safety and efficacy.

Acute epidural hemorrhage following burr-hole irrigation for chronic subdural hematoma: A possible association with the diploic veins

A 50-year-old man presented with headache and left hemiparesis. No noticeable preceding head trauma was observed. Computed tomography (CT) scans revealed a compressive chronic subdural hematoma (CSDH). The patient underwent burr-hole irrigation, during which he was considerably restless. In addition, extensive avulsion was found in the parietal dura mater posterior to the burr hole. CT performed immediately after the surgery revealed the emergence of a thick epidural hematoma (EDH) located posterior to the burr-hole. During emergency craniotomy for the EDH, there was no identifiable injury to the dura mater or the meningeal vessels. However, a review of the CT scans confirmed well-developed diploic spaces just above the center of the EDH, with connecting channels between the diploic spaces and extracranial sites. Based on these observations, we assumed that the diploic vein might have caused the EDH. Diploic veins can cause AEDH after burr hole irrigation for CSDH. Appropriate intraoperative sedation and protective irrigation maneuvers can reduce the risk of such AEDH.

Efficacy and Safety of Atorvastatin for Chronic Subdural Hematoma: An Updated Systematic Review and Meta-Analysis

BACKGROUND

Chronic subdural hematoma (CSDH) is a common neurological condition, especially in the elderly population. Atorvastatin has shown the potential to reduce the recurrence of CSDH and improve overall outcomes. New studies have emerged since the last meta-analysis, increasing the sample size and the variety of outcomes analyzed.

METHODS

We searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials for studies comparing the use of atorvastatin in CSDH patients with a control group or placebo. The primary outcome was the recurrence of CSDH. Secondary outcomes of interest were hematoma volume, composite adverse effects, mortality, and neurological function, measured by the Glasgow Outcome Scale and Barthel index for activities of daily living.

RESULTS

Seven studies, of which 2 were randomized controlled trials, were included, containing 1192 patients. Overall recurrence significantly decreased compared to the control group (risk ratio [RR] 0.46; 95% confidence interval [CI] 0.25-0.83; P=0.009). The benefits of atorvastatin were sustained in the subgroup analysis of patients who underwent initial conservative therapy (RR 0.40; 95% CI 0.22-0.70; P=0.001). However, there was no significant difference when atorvastatin was combined with surgical intervention (RR 0.53; 95% CI 0.21-1.32; P=0.17). Adverse effects were not increased by atorvastatin (RR 0.82; 95% CI 0.51-1.34; P=0.44).

CONCLUSIONS

Atorvastatin might be beneficial in reducing CSDH recurrence, especially in conservative treatment patients. Atorvastatin was not significantly associated with adverse effects. Larger, higher-quality randomized studies are needed to adequately evaluate the efficacy, safety, and optimal dose of atorvastatin in CSDH patients.

Endoscopic Management of Chronic Subdural Hematoma Using a Novel Brain Retractor

BACKGROUND

Endoscopic procedures are useful in chronic subdural hematoma especially when there are septations, solid/organized hematoma, and the presence of bridging or neovessels in the cavity. Visualizing the distal hematoma cavity by a rigid scope is challenging in large and curved ones due to the hindrance by the brain surface. Combining rigid endoscopy and brain retractor can overcome this limitation.

METHODS

A retrospective study of 248 patients managed by endoscopic technique was performed and the relevant literature was reviewed.

RESULTS

The brain retractor was used in all patients. Average operative time, subgaleal drainage duration, and hospital stay were 56 minutes, 3.1 days, and 4.6 days, respectively. The average preoperative Glasgow coma scale (GCS) score was 12, which improved to 14 and 15 in 223 and 23 patients, respectively at discharge. There were solid clots, septations, bridging vessels, curved hematoma cavities, rapid expansion of the brain after partial hematoma removal, and recurrences in 59, 52, 15, 49, 19, and 2 patients, respectively. There were 2 deaths, without any procedure-related mortality.

CONCLUSIONS

Endoscope was very effective and safe in the management of chronic subdural hematoma, especially in about 51% patients with solid clots, septations, and bridging vessels which could have been difficult to treat by conventional burr hole. It can avoid craniotomy in such patients. Good visualization and complete hematoma removal were possible with the help of an endoscope and brain retractor in about 27% of patients which could have been difficult with a rigid endoscope alone.

Backup Frontal Drainage System for Urgent Tension Pneumocephalus Management After Chronic Subdural Hematoma Surgery: A Retrospective Cohort Study

OBJECTIVE

To describe a simple variation of burr hole craniostomy for the management of chronic subdural hematoma (CSDH) that uses a frontal drainage system to facilitate timely decompression in the event of tension pneumocephalus and spares the need for additional surgery.

METHODS

We conducted a retrospective analysis of 20 patients with CSDH who underwent burr hole craniostomy and 20 patients who underwent the same procedure alongside the placement of a 5 Fr neonatal feeding tube as a backup drainage for the anterior craniostomy. Depending on the situation, the secondary drain stayed for a maximum of 72 hours to be opened and used in emergency settings for drainage, aspiration, or as a 1-way valve with a water seal.

RESULTS

The outcomes of 20 patients who underwent this procedure and 20 controls are described. One patient from each group presented tension pneumocephalus. One was promptly resolved by opening the backup drain under a water seal to evacuate pneumocephalus and the other patient had to undergo a reopening of the craniostomy.

CONCLUSIONS

The described variation of burr hole craniostomy represents a low-cost and easy-to-implement technique that can be used for emergency decompression of tension pneumocephalus. It also has the potential to reduce reoperation rates and CSDH recurrence. Prospective controlled research is needed to validate this approach further.

Long-term postoperative prognosis and associated risk factors of chronic subdural hematoma in the elderly

Surgical treatment for chronic subdural hematoma（CSDH）has contributed to good outcome. However, several recent studies have revealed that surgical outcomes for elderly patients were not decisively good. In this study, prognosis of CSDH patients in elderly were analyzed. This study included 232 CSDH patients who were treated in our department and 2 affiliated hospitals, and poor prognosis was defined as aggravation of modified Rankin scale (mRS) at examination comparing with that at discharge, or mRS 3 and higher at examination. We collected data from medical records and questionnaires on the following clinical characteristics of patients: age, sex, findings at admission, medication of antiplatelets and anticoagulants, radiological findings on computed tomography, recurrence, place of discharge, perioperative systemic complications, and mRS at discharge and at examination. The cut-off value of age for poor prognosis of all CSDH patients was 74 years old in this study. In multivariate analysis of all cases, age was prognostic factor for poor outcome:75 years old or higher（p=0.0002）. In this group, mRS at discharge(p=0.0184) and postoperative medical diseases(p<0.0001) were the risk factors of poor prognosis. In this present study, high age and activities of daily life（ADL） at discharge were significant prognostic factors for poor outcome of CSDH. Improvement of ADL at discharge with care for postoperative systemic complications and careful rehabilitation can contribute to good prognosis for CSDH in elderly patients.

Postoperative elevated bed header position versus supine in the management of chronic subdural hematoma: a systematic review and meta-analysis

BACKGROUND

Chronic subdural hematoma (CSDH) is a prevalent type of intracranial hemorrhage. Surgical interventions, such as Twist Drill Craniostomy and Burr Hole Craniostomy, are employed for its treatment. However, limited information exists regarding the impact of postoperative head position (supine vs. elevated) on clinical outcomes. We aim to assess whether patients' head position after surgery influences their prognosis.

METHOD

We conducted a PRISMA-compliant systematic review and meta-analysis. Our search encompassed PubMed, Cochrane CENTRAL, Scopus, Web of Science, and Embase databases to identify relevant published studies. Data were meticulously extracted, pooled using a fixed model, and reported as risk ratios (RR) with 95% confidence intervals (CI). Statistical analysis was performed using R and Stata MP v.17.

RESULTS

Five studies involving 284 patients were included in our meta-analysis. We focused on three primary clinical outcomes, comparing the supine and elevated header positions. Notably, there was no statistically significant difference between the supine and elevated positions in terms of recurrence rate (RR 0.77, 95% CI [0.44, 1.37]), second intervention for recurrence (RR 1.07, 95% CI [0.42, 2.78]) and postoperative complications (RR 1.16, 95% CI [0.70, 1.92]).

CONCLUSION

Current studies have proved no difference between supine and elevated bed header positions regarding recurrence rate, second intervention for recurrence, and postoperative complications. Future RCTs with long-term follow-ups are recommended.

Facial nerve palsy after middle meningeal artery embolization for chronic subdural hematoma: a case report

Middle meningeal artery embolization (MMAE) has emerged as a safe and efficacious alternative to surgery for the treatment of new or recurrent chronic subdural hematoma (CSDH). Several complications such as facial palsy may suddenly occur even in the absence of evident dangerous anastomoses in the angiogram. We herein present a case-report of left facial nerve palsy after MMAE.