Risk factors for the occurrence of chronic subdural haematomas after neurosurgical procedures

Chronic subdural haematoma (CSDH) is a rare clinical complication of neurosurgical procedures. CSDH occurs sporadically after aneurysm clipping surgery and revascularisation surgery but the risk factors are not known. The present study reviewed 6613 consecutive neurosurgical procedures performed from January 1987 to July 2001, and identified 621 cases of CSDH. Fifty of these 621 cases had a past history of neurological disorders treated by neurosurgery. This study evaluated these 50 cases in order to elucidate the clinical and radiological characteristics of CSDH after neurosurgery and to investigate the etiology for identifying in the risk factors of CSDH as a postoperative complication. The incidence of CSDH after neurosurgery was 0.8% (50/6613). Twenty-seven of the 50 patients with a past history of neurosurgery had undergone aneurysm clipping surgery. The incidence after clipping surgery was 2.4%. Twelve of these 27 cases also underwent ventriculoperitoneal shunting. Three patients had postoperative CSDH after arachnoid cyst opening and/or shunting. The incidence was highest at 7.5%. Three patients had postoperative CSDH after brain tumour surgery. The incidence was low at 0.4%. However, the ventricular cerebrospinal fluid (CSF) space was opened during tumour removal in 2 of these 3 patients. Communication of the subarachnoid space to the subdural space is considered to be one of the causative factors and excessive CSF shunting facilitates formation of CSDH after neurological surgery. Repair of arachnoid tearing during neurosurgery and avoidance of excessive CSF shunting may reduce the risk of CSDH after neurosurgery.

Independent predictors of recurrence of chronic subdural hematoma: results of multivariate analysis performed using a logistic regression model

OBJECT

The authors attempted to determine independent predictors that contribute to the recurrence of chronic subdural hematoma (CSDH).

METHODS

A total of 105 consecutive patients who underwent surgery for CSDH were included in this study. Eleven patients underwent a repeated operation because the CSDH recurred. Univariate and multivariate analyses were performed to assess the relationships among various variables and CSDH recurrence. Finally, four variables were found to be independently associated with the recurrence of CSDH: 1) absence of a multiplicity of hematoma cavities on CT scans; 2) presence of a history of seizure; 3) width of the hematoma; and 4) absence of a history of diabetes mellitus (DM).

CONCLUSIONS

As previously reported, the width of the hematoma is related to the incidence of CSDH recurrence. In this study, the lack of a multiplicity of hematoma cavities was the favorite predictor of CSDH recurrence. In addition, histories of seizure and no past DM are closely related to the incidence of CSDH recurrence.

Chronic subdural haematoma after snowboard head injury

Two cases of chronic subdural haematoma following a snowboard head injury are reported. Although such cases are rare in sport, the risk in snowboarders is higher than expected. Evaluation of a snowboarder with a history of head injury, albeit mild, who complains of headaches should include computed tomography or magnetic resonance imaging to allow rapid identification of any intracranial pathology.

[Chronic subdural hematoma and extramedullary erythropoiesis in an infant]

We report the case of a six-month old child with bilateral chronic subdural hematoma of unknown origin containing erythroblasts, metamyelocytes and blast-like cells. No such cells were found in venous blood. No primary neoplastic disorder was found. Throughout a 19-month follow-up period, general and neurodevelopmental examination remained normal with complete resolution of the subdural haematoma in the presence of macrocephaly. We discuss the origin and role of these cells.

[Chronic subdural hematoma: a disease of elderly people]

BACKGROUND

The lack of specificity and heterogeneity of the clinical picture of chronic subdural hematoma, hampers its diagnosis.

AIM

To report the experience of a Neurosurgical Service in chronic subdural hematoma.

PATIENTS AND METHODS

One hundred patients (77 male, mean age 77 +/- 13 years) with chronic subdural hematoma were analyzed.

RESULTS

The main clinical presentations were mental status changes (50%) and progressive focal neurological deficit (46%). Five cases presented as a transient neurological deficit. All patients were treated with burr hole drainage. Thirteen had recurrence of the hematoma and they were reoperated. The surgical mortality was 3%. Eighty seven patients were followed for a mean of 66 months. Eighty one of these had a complete recovery, 6 had permanent neurological deficit and 2 of these were unable to care for themselves. Bad prognosis was associated with the absence of a previous trauma to explain the hematoma and symptoms of dementia as the clinical presentation.

CONCLUSIONS

Most patients with chronic subdural hematoma treated with burr hole drainage have a good outcome.

The role of postoperative patient posture in the recurrence of chronic subdural hematoma: a prospective randomized trial

BACKGROUND

Chronic subdural hematoma is known to have a significant recurrence rate. In this report, we evaluate the relationship between the recurrence rate of chronic subdural hematoma and postoperative patient posture.

METHODS

We conducted a prospective randomized study of 46 patients with chronic subdural hematoma treated surgically at the Osaka City General Hospital from January 1997 to December 1999. In Group A, the patients were kept in a supine position for 3 days after the operation. In Group B, the patients assumed a sitting position on the day after the operation.

RESULTS

The recurrence rates in Group A and Group B were not significantly different.

CONCLUSIONS

Assuming an upright posture soon after operation in cases of chronic subdural hematoma is not thought to be a risk factor for recurrence.

Acute subdural hematoma in infancy

BACKGROUND

Acute subdural hematoma in infants is distinct from that occurring in older children or adults because of differences in mechanism, injury thresholds, and the frequency with which the question of nonaccidental injury is encountered. The purpose of this study is to analyze the clinical characteristics of acute subdural hematoma in infancy, to discover the common patterns of this trauma, and to outline the management principles within this group.

METHODS

Medical records and films of 21 cases of infantile acute subdural hematoma were reviewed retrospectively. Diagnosis was made by computed tomography or magnetic resonance imaging. Medical records were reviewed for comparison of age, gender, cause of injury, clinical presentation, surgical management, and outcome.

RESULTS

Twenty-one infants (9 girls and 12 boys) were identified with acute subdural hematoma, with ages ranging from 6 days to 12 months. The most common cause of injury was shaken baby syndrome. The most common clinical presentations were seizure, retinal hemorrhage, and consciousness disturbance. Eight patients with large subdural hematomas underwent craniotomy and evacuation of the blood clot. None of these patients developed chronic subdural hematoma. Thirteen patients with smaller subdural hematomas were treated conservatively. Among these patients, 11 developed chronic subdural hematomas 15 to 80 days (mean = 28 days) after the acute subdural hematomas. All patients with chronic subdural hematomas underwent burr hole and external drainage of the subdural hematoma. At follow-up, 13 (62%) had good recovery, 4 (19%) had moderate disability, 3 (14%) had severe disability, and 1 (5%) died. Based on GCS on admission, one (5%) had mild (GCS 13-15), 12 (57%) had moderate (GCS 9-12), and 8 (38%) had severe (GCS 8 or under) head injury. Good recovery was found in 100% (1/1), 75% (8/12), and 50% (4/8) of the patients with mild, moderate, and severe head injury, respectively. Sixty-three percent (5/8) of those patients undergoing operation for acute subdural hematomas and 62% (8/13) of those patients treated conservatively had good outcomes.

CONCLUSIONS

Infantile acute subdural hematoma if treated conservatively or neglected, is an important cause of infantile chronic subdural hematoma. Early recognition and suitable treatment may improve the outcome of this injury. If treatment is delayed or the condition is undiagnosed, acute subdural hematoma may cause severe morbidity or even fatality.

Arachnoid cyst is a risk factor for chronic subdural hematoma in juveniles: twelve cases of chronic subdural hematoma associated with arachnoid cyst

Chronic subdural hematoma (CSDH) tends to occur in elderly patients with a history of mild head injury at a few months prior to the onset of symptoms. Intracranial arachnoid cyst is believed to be congenital and sometimes becomes symptomatic in pediatric patients. These two distinct clinical entities sporadically occur in the same young patient. Twelve of 541 cases of CSDH surgically treated in our institution had associated arachnoid cyst. The clinical and radiological characteristics of the cases of CSDH associated with arachnoid cyst were retrospectively analyzed and compared with those of CSDH without arachnoid cyst. Arachnoid cysts were located in the middle fossa (eight cases), convexity (two cases), and posterior fossa (two cases). Three cysts were less than 20 mm in diameter. The 12 patients with CSDH and arachnoid cyst (mean age 27.8 +/- 19.7 years) were significantly younger (p < 0.001) than the patients with CSDH without arachnoid cyst (69.5 +/- 13.7 years). Five of the 12 patients were pediatric cases (< 15 years old). The clinical symptoms were also significantly different. The most frequent symptom was headache followed by vomiting in the patients with arachnoid cyst, while gait disturbance and hemiparesis predominated in patients without arachnoid cyst. Hematoma evacuation through burr holes improved the symptoms in all patients with arachnoid cyst. We conclude that even a small arachnoid cyst can be a risk factor for CSDH after mild head injury in young patients and symptoms of increased intracranial pressure are common. Hematoma evacuation is adequate at first operation. If the preoperative symptoms persist, additional arachnoid cyst surgery should be considered. The present results also suggest that CSDH formation may be preceded by subdural hygroma caused by the rupture of arachnoid cyst.

[Difficulties in forensic medical evaluation of some forms of craniocerebral injury]

Conclusions of 41 repeated expert evaluations of craniocerebral injuries within the framework of criminal and civil cases investigation are analyzed. Some aspects of clinical and forensic medical diagnosis of lethal and nonlethal injuries to the head, evaluation of the quality of medical care, and qualification of the severity of harm to health are discussed. Causes of typical expert errors and approaches to their prevention are shown.

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

OBJECT

Thrombomodulin is a thrombin receptor on vascular endothelial cells that is highly expressed when these cells are injured, and it has anticoagulating activity. The authors investigated thrombomodulin expression to clarify why chronic subdural hematomas (CSDHs) continue to grow slowly, like a tumor, and are liquefied.

METHODS

Burr hole craniotomy and drainage were performed in all 35 patients with CSDH who were included in the study. The plasma-soluble thrombomodulin and blood clotting factor values were determined in the hematoma and in peripheral blood. In the seven most recent cases, the plasma-soluble thrombomodulin values were determined in the residual hematoma collected from the drainage tube the day after surgery. The outer membranes of the CSDH that were obtained as specimens at operation were stained with monoclonal antibody against thrombomodulin for immunohistochemical studies. The plasma-soluble thrombomodulin values were higher (p < 0.0001), and conversely the values for factors V and VIII were lower in the hematoma than in peripheral blood (p < 0.0001). The plasma-soluble thrombomodulin values were lower in the residual hematomas than in the same lesions at operation (p = 0.018). The endothelial cells on the sinusoidal vessels exhibited immunoreactivity with thrombomodulin antibody in 28 (93%) of 30 cases.

CONCLUSIONS

The thrombomodulin is expressed on the sinusoidal vessels, and the blood coagulation system is inhibited in the hematoma. These findings indicate that these vessels are continuously injured and fail to heal. As a result, the bleeding from the sinusoidal vessels may persist, and the hematoma may grow slowly and fail to coagulate. It is suspected that transmitted pulsation variations in the hematoma cavity generate sinusoidal vessel injury.

Chronic subdural haematoma in young and extremely aged adults: a comparative study of two age groups

To compare the clinical presentation, etiological factors and the outcome of chronic subdural haematoma (CSDH) in young and old adults, a retrospective analysis was performed by differentiating young adults, age<40 years (n=24) versus extremely aged adults, age>75 years (n=51). The clinical data, computed tomography (CT) findings and surgical outcome were recorded for analysis. We observed certain characteristics particular to young CSDH patients, higher incidence of headache (P<0.001) and vomiting (P=0.009), the shorter duration from trauma to operation (P=0.018) and more severe traumatic episodes (P=0.001). The older patients had a higher frequency of mental change (P=0.006), motor deficits (P=0.014) and larger haematomas (P<0.001). The surgical complication rate was not statistically different between the two age groups. An understanding of the varied clinical presentation of CSDH is essential to stimulate clinical suspicion and prompt evaluation, particularly for the differences between young and extremely aged patients.

Epidural B cell non-Hodgkin's lymphoma associated with chronic subdural hematoma

BACKGROUND

Chronic subdural hematoma generally occurs in elderly patients, who are also prone to neoplasm. However, the association of chronic subdural hematoma and intracranial neoplasm is rare.

CASE DESCRIPTION

An elderly woman harboring a chronic subdural hematoma underlying an epidural extension of a malignant B cell non-Hodgkin's lymphoma is reported. Infiltration of the tumor and obstruction of the dural veins with stasis and rupture of the capillary net may have been the mechanism that led to formation of the hematoma.

CONCLUSIONS

In elderly patients harboring chronic subdural hematoma with mural isodensity on CT who have no history or an uncertain history of head trauma, one should consider the possibility of neoplasm, although it is rare. Chronic subdural hematoma associated with epidural extension of B cell non-Hodgkin's lymphoma is exceptional. Screening for other systemic manifestations should be carried out. Radiotherapy, alone or in combination with chemotherapy, should be considered after surgical removal.

Chronic subdural haematoma in the elderly

Chronic subdural haematoma is predominantly a disease of the elderly. It usually follows a minor trauma. A history of direct trauma to the head is absent in up to half the cases. The common manifestations are altered mental state and focal neurological deficit. Neurological state at the time of diagnosis is the most important prognostic factor. Morbidity and mortality is higher in the elderly but outcome is good in patients who undergo neurosurgical intervention.

Subdural haematoma after dural puncture headache treated by epidural blood patch

Subdural haematoma is a well-documented complication of accidental dural puncture, and is thought to be preventable by prompt treatment with an epidural blood patch. An accidental dural puncture occurred in a 39-yr-old primagravida during the siting of an epidural catheter for pain relief in labour. Twenty hours after the puncture, the mother developed a typical postdural puncture headache, which increased in severity over the subsequent 24 h. An epidural blood patch was performed at 48 h, and this initially relieved the headache. After discharge from hospital, and 14 days after the dural puncture, the headache recurred, together with expressive dysphasia, poor co-ordination and sensory loss in the right arm. A magnetic resonance imaging scan demonstrated a left sided subdural haematoma, which was drained successfully with complete recovery.

[Relationship of postoperative residual air and recurrence in chronic subdural hematoma]

The possibility exists that residual air after surgery is one cause of recurrence of chronic subdural hematoma. We have devised a new simple method which decreases postoperative residual air, using external drainage and an endoscope. First, we make endoscopic observations of the inner aspect of the hematoma cavity. Then, we insert external drainage apparatus into the most frontal area of the hematoma cavity, we regard this location as the most appropriate place to ensure most effective drainage. The present study included 37 chronic subdural hematomas in 32 patients who had been treated between January and December, 1999. Their ages ranged from 48 to 86 years old, with an average of 72 years. Insertion of external drainage in the most frontal area of the hematoma cavity was successfully achieved in 27 (73%, Group I) out of 37 cases and resulted in no recurrence. In the remaining 10 hematomas (27%, Group II), external drainage was not able to be inserted in the most frontal area, and four hematomas (40%) had recurrence (p < 0.01 vs Group I). Insertion in the most frontal area of the hematoma cavity decreases residual air after surgery, and may be effective for the prevention of recurrence of chronic subdural hematoma.

The fate of traumatic subdural hygroma in serial computed tomographic scans

We reviewed serial computed tomographic (CT) scans of 58 patients with traumatic subdural hygroma (SDG) to investigate its natural history. All were re-evaluated with a special reference to the size and density of SDG. Thirty-four patients (58.6%) were managed conservatively and 24 patients (41.4%) underwent surgery. The lesion was described as remained, reduced, resolved, enlarged and changed. Means of interval from injury to diagnosis and any changes in CT were calculated. SDGs were resolved in 12 (20.7%), reduced in 15 (25.9%), remained in 10 (17.2%), enlarged in 2 (3.4%), and changed into chronic subdural hematoma (CSDH) in 19 patients (32.8%). SDG was diagnosed at 11.6 days after the injury. It was enlarged at 25.5 days, remained at 46.0 days, reduced at 59.3 days, resolved at 107.5 days, and changed into CSDH at 101.5 days in average. SDGs were developed as delayed lesions, and changed sequentially. They enlarged for a while, then reduced in size. The final path of a SDG was either resolution or CSDH formation. Nearly half of SDGs was resolved or reduced within three months, however, 61.3% of unresolved or unreduced SDG became iso- or hyperdense CSDH. These results suggest that the unresolved SDG is the precursor of CSDH.

Chronic subdural hematoma in children

Chronic subdural hematoma (CSH) is generally a disease affecting the elderly and infants. In infants, the process is particularly confusing and frequently misunderstood. In the pediatric population, CSH is just one of a group of sometimes related conditions known as extracerebral fluid collections. In the past, extracerebral fluid collections, in general, and CSHs, in particular, have been inaccurately or incompletely described. Modern neuroimaging techniques, however, have greatly advanced our understanding of these conditions. Surprisingly little literature exists on the subject, and publications before the advent of modern computed tomography and magnetic resonance imaging should be interpreted with caution.

Chronic subdural hematoma in adult and elderly patients

Chronic subdural hematomas display a wide diversity of features in adults, often simulating other neurologic and psychiatric disease processes. This is particularly problematic in elderly patients, for whom more nonspecific clinical presentations are common. Recognition of these features is the key to early diagnosis in elderly patients, who exhibit a markedly increased incidence of this disease. Prompt diagnosis prevents delays that may lead to increased morbidity in these patients.

Interhemispheric and bilateral chronic subdural hematoma

Data on bilateral chronic subdural hematomas (CSHs) are scant, including information on the frequency of symptoms, response to various treatments, and postoperative complications, compared with data on unilateral CSH. Bilateral CSHs constitute a fair portion of CSHs, especially in patients older than 75 years and in those with coagulation abnormalities. The presenting symptoms are those of increased intracranial pressure and mass effect. Computed tomography of the head is the best study for the diagnosis and follow-up of bilateral CSHs, although magnetic resonance imaging is a more sensitive modality. Treatment of bilateral CSHs presents its own unique set of problems. New hemorrhage on the contralateral side and shift of midline structures are concerns and can be avoided by simultaneous bilateral decompression. Twist-drill craniostomy, burr-hole washout, and craniotomy are the mainstays of treatment, with subdural-peritoneal shunting reserved for intractable cases.