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Critical Depressed Brain Volume Influences the Recurrence of Chronic Subdural Hematoma after Surgical Evacuation. Sci Rep 2020; 10:1145. [PMID: 31980723 PMCID: PMC6981211 DOI: 10.1038/s41598-020-58250-w] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 01/13/2020] [Indexed: 11/25/2022] Open
Abstract
Recurrence of chronic subdural hematoma (CSDH) frequently occurs after surgical evacuation. However, the value of follow-up postoperative imaging and measuring volumetric factors to predict recurrence are still controversial. Herein, we aimed to assess the optimal timing for follow-up referential imaging and the critical depressed brain volume for CSDH recurrence. A total of 291 patients with CSDH who underwent burr hole craniotomy between January 2012 and December 2018 were consecutively enrolled in this study. Patients’ medical records and radiologic data were evaluated to predict the recurrence and analyzed using receiver operating characteristics (ROC) and binary logistic regression. Of the 291 patients, 29 (10.0%) showed recurrence after surgical evacuation. Based on ROC analysis, comparisons of depressed brain volume pre-operation, 24 h post-operation, and 7 days post-operation showed that the depressed brain volume at 7 days after surgery featured the largest area under the curve (AUC: 0.768, 95% CI, 0.709–0.811). The cut-off value of the depressed brain volume on postoperative day 7 was 51.6 cm3; this value predicted the recurrence of CSDH with a sensitivity and specificity of 79.3% and 67.9%, respectively. In the multivariate analysis, the depressed brain volume (>50 cm3) at 7 days was the sole significant risk factor related to the recurrence of CSDH in this series (OR: 6.765, 95% CI, 2.551–17.942, p < 0.001). The depressed brain volume > 50 cm3 visualized on CT scans at postoperative 7 day is the critical volume affecting recurrence of CSDHs. This result could be helpful carrying in patients with CSDH to determine the proper postoperative treatment strategy.
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Huang CT, Sun JM, Hsieh CT, Chen YH, Chang JY, Wong CS. Association between nonsteroidal anti-inflammatory drugs and lower incidence of surgical treatment of chronic subdural hematoma: A population-based study. FORMOSAN JOURNAL OF SURGERY 2020. [DOI: 10.4103/fjs.fjs_23_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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153
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Kung WM, Lin MS. CT-Based Quantitative Analysis for Pathological Features Associated With Postoperative Recurrence and Potential Application Upon Artificial Intelligence: A Narrative Review With a Focus on Chronic Subdural Hematomas. Mol Imaging 2020; 19:1536012120914773. [PMID: 32238025 PMCID: PMC7290264 DOI: 10.1177/1536012120914773] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 10/23/2019] [Accepted: 02/14/2020] [Indexed: 02/05/2023] Open
Abstract
Chronic subdural hematomas (CSDHs) frequently affect the elderly population. The postoperative recurrence rate of CSDHs is high, ranging from 3% to 20%. Both qualitative and quantitative analyses have been explored to investigate the mechanisms underlying postoperative recurrence. We surveyed the pathophysiology of CSDHs and analyzed the relative factors influencing postoperative recurrence. Here, we summarize various qualitative methods documented in the literature and present our unique computer-assisted quantitative method, published previously, to assess postoperative recurrence. Imaging features of CSDHs, based on qualitative analysis related to postoperative high recurrence rate, such as abundant vascularity, neomembrane formation, and patent subdural space, could be clearly observed using the proposed quantitative analysis methods in terms of mean hematoma density, brain re-expansion rate, hematoma volume, average distance of subdural space, and brain shifting. Finally, artificial intelligence (AI) device types and applications in current health care are briefly outlined. We conclude that the potential applications of AI techniques can be integrated to the proposed quantitative analysis method to accomplish speedy execution and accurate prediction for postoperative outcomes in the management of CSDHs.
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Affiliation(s)
- Woon-Man Kung
- Division of Neurosurgery, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Muh-Shi Lin
- Division of Neurosurgery, Department of Surgery, Kuang Tien General Hospital, Taichung, Taiwan
- Department of Biotechnology and Animal Science, College of Bioresources, National Ilan University, Yilan, Taiwan
- Department of Biotechnology, College of Medical and Health Care, Hung Kuang University, Taichung, Taiwan
- Department of Health Business Administration, College of Medical and Health Care, Hung Kuang University, Taichung, Taiwan
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154
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Brazdzionis J, Patchana T, Wiginton JG, Wacker MR, Menoni R, Miulli DE. Intracatheter Tissue Plasminogen Activator for Chronic Subdural Hematomas after Failed Bedside Twist Drill Craniostomy: A Retrospective Review. Cureus 2019; 11:e6472. [PMID: 32025399 PMCID: PMC6984181 DOI: 10.7759/cureus.6472] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Introduction Chronic subdural hematomas (cSDH) are common in neurosurgery with various symptoms and significant morbidity and mortality. Treatment varies with procedures including twist-drill (TD) craniostomy, craniotomy, burr hole craniostomy, and craniectomy. Newer treatments including middle meningeal artery embolization are also being explored as no treatment has been determined to be optimal. Due to the lack of consensus treatment, tissue plasminogen activator (tPA) has begun to be investigated to promote drainage and has shown promise in some early studies in reducing recurrence rates. We retrospectively reviewed patients who underwent TD craniostomy and received intracatheter tPA to evaluate the safety and efficacy of this practice. Methods A single-center retrospective review from December 2018 through August 2018 occurred for patients with cSDH 18 years of age or older who underwent a bedside TD craniostomy. Inclusion criteria included all patients who underwent treatment with TD craniostomy for drainage of cSDH during the time period in which tPA protocol was adopted as a possible therapeutic measure at our center. Exclusion criteria included all patients less than age 18 or incarcerated. Patients were stratified into two groups those that received tPA per our center's neurosurgical protocol and those that received drainage alone. Data collected included demographics, hospital/intensive care unit (ICU) length of stay, operative intervention, cSDH thickness throughout stay, length of drainage, and Glasgow Coma Scale (GCS) on arrival and discharge with analysis performed using t-tests. Results In all, 20 patients met inclusion: six received tPA at 48 hours per the institutional neurosurgical protocol and 14 did not. The average thickness of cSDH on arrival was significantly larger in the tPA group (26.5 mm vs 14.46 mm, p = 0.0029). Arrival and discharge GCS, average daily drainage, length of stay parameters, and percent change in thickness did not differ between tPA and no tPA groups. The average daily drainage was significantly less prior to the administration of tPA in the tPA group than in the cohort of not receiving tPA (30.71 mL vs 68.99 mL; p = 0.011). Average drainage in patients who received tPA after administration was significantly higher compared to pre-tPA values (131.39 mL vs 30.71 mL; p = 0.046). No patients were readmitted for re-accumulation or required an operating room procedure. There were no adverse outcomes identified through the instillation of tPA. Conclusion Intracatheter tPA increased drainage rates in the assessment of pre- and post-tPA values when administered at 48 hours after subdural drain (SDD) placement. Patients who received benefits from tPA tended to have larger subdural hematomas and less drainage prior to the instillation of tPA than patients that benefited from drainage alone. Larger prospective studies should investigate early treatment with tPA to identify if tPA is efficacious for all patients after TD craniostomy and to optimize patient selection with regard to thrombolytic therapy.
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Affiliation(s)
- James Brazdzionis
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Tye Patchana
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - James G Wiginton
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | | | - Rosalinda Menoni
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Dan E Miulli
- Neurosurgery, Arrowhead Regional Medical Center, Colton, USA
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155
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Nassiri F, Hachem LD, Wang JZ, Badhiwala JH, Zadeh G, Gladstone D, Scales DC, Pirouzmand F. Reinitiation of Anticoagulation After Surgical Evacuation of Subdural Hematomas. World Neurosurg 2019; 135:e616-e622. [PMID: 31874290 DOI: 10.1016/j.wneu.2019.12.080] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 12/12/2019] [Accepted: 12/13/2019] [Indexed: 01/23/2023]
Abstract
BACKGROUND Chronic subdural hematoma (cSDH) is an increasingly common condition due to the growing use of anticoagulation. Currently, there remains a lack of evidence to guide the optimal timing of anticoagulant reinitiation for stroke prevention in atrial fibrillation after cSDH evacuation. We aimed to better understand the perceived risks of hemorrhagic and embolic complications along with current practice patterns on restarting anticoagulation after surgical evacuation of cSDH. METHODS We conducted a survey of Canadian neurosurgeons and stroke neurologists using a novel self-administered questionnaire using clinical cases that included questions on clinical experience, practice setting, practice patterns, and perceptions on stroke/bleeding risk with anticoagulation reinitiation after cSDH evacuation. The instrument was evaluated for clinical sensibility by 5 neurosurgeons, neurologists, and intensivists. RESULTS The response rate after 4 mailings was 40% for neurosurgeons (55/136) and 21% for stroke neurologists (26/122). Almost all participants would restart anticoagulation for stroke prevention in atrial fibrillation after cSDH evacuation (91.8% in low-risk patients, 98.6% in high-risk patients). Time to reinitiation of anticoagulation varied considerably, particularly for high-risk patients where 36% of participants would restart anticoagulation within 1 week of surgery, 44% between 1 and 4 weeks after surgery, and 19% after 4 weeks postoperatively. The perceived risk of stroke and SDH reaccumulation varied considerably among participants and was dependent on timing of anticoagulation reinitiation. CONCLUSIONS There is considerable variation in current practice patterns and perceived risks of embolic and hemorrhagic complications with anticoagulation reinitiation after cSDH evacuation. These results demonstrate clinical equipoise that warrant further targeted investigation in large-scale randomized controlled trials.
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Affiliation(s)
- Farshad Nassiri
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Laureen D Hachem
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Justin Z Wang
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Jetan H Badhiwala
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Gelareh Zadeh
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - David Gladstone
- Division of Neurology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Damon C Scales
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Farhad Pirouzmand
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Division of Neurosurgery, Sunnybrook Health Science Centre, Toronto, Canada.
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156
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Robinson D, Khoury JC, Kleindorfer D. Regional Variation in the Management of Nontraumatic Subdural Hematomas Across the United States. World Neurosurg 2019; 135:e418-e423. [PMID: 31862343 DOI: 10.1016/j.wneu.2019.12.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 12/02/2019] [Accepted: 12/03/2019] [Indexed: 11/26/2022]
Abstract
BACKGOUND Nontraumatic subdural hematomas are a common indication for inpatient hospitalization in the United States, yet there is little high-quality evidence regarding which patients should receive surgical or medical treatment. We sought to assess variation in surgical management and medical treatment with steroids for nontraumatic subdural hematomas across the United States. METHODS Using the Premier database, we analyzed patients with a primary discharge diagnosis of nontraumatic subdural hematoma in 2014. International Classification of Diseases, Ninth Revision, procedure codes were used to identify patients who underwent surgical management, and pharmacy data were used to identify patients treated with dexamethasone. Univariable and multivariable analyses were used to examine the association of age, race, sex, academic versus nonacademic center, and regions of the United States with conservative or surgical management. RESULTS There were 3915 inpatient hospitalizations for nontraumatic subdural hematomas in 2014 in the Premier database, of whom 1860 (47.5%) underwent surgery, and 360 (9.2%) underwent treatment with dexamethasone, either as a primary treatment or as an adjuvant to surgery. Older age, female sex, and being managed outside of the Western U.S. region were associated with a lower likelihood of undergoing surgical management on multivariable analysis; only younger age was associated with a greater likelihood of being treated with dexamethasone. CONCLUSIONS There is considerable variability in surgical management of nontraumatic subdural hematomas across the United States based on age, sex, and region. Future studies should explore the reasons for the variability and attempt to better clarify indications for surgical management of subdural hematomas.
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Affiliation(s)
- David Robinson
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio, USA.
| | - Jane C Khoury
- Division of Biostatistics and Epidemiology, Cincinnati Children's Medical Center, Cincinnati, Ohio, USA; Department of Pediatrics, University of Cincinnati of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Dawn Kleindorfer
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio, USA
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157
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Kotwica Z, Saracen A, Dziuba I. Chronic Subdural Hematoma (CSH) is Still an Important Clinical Problem. Analysis of 700 Consecutive Patients. Transl Neurosci 2019; 10:260-263. [PMID: 31737353 PMCID: PMC6843484 DOI: 10.1515/tnsci-2019-0042] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 02/15/2019] [Indexed: 11/15/2022] Open
Abstract
Background Chronic subdural hematoma (CSH) is still an important neurosurgical problem and the number of patients increases despite the progress in early diagnosis of cerebral lesions. Methodology We analyzed a group of 700 consecutive patients treated in neurosurgical departments for CSH. Clinical state on admission was evaluated according to the Markwalder scale, all patients had CT studies and were operated using craniotomy or burr holes with closed system drainage techniques. Results More than 50% had extensive intracranial bleeding, almost half of the patients were treated with oral anticoagulants. The patients with extensive fresh bleeding were in significantly worse states on admission and were treated by craniotomy and external capsulectomy (42%). All the others had burr holes and closed system drainage of the subdural space. Results of treatment were acceptable, 2% died, and 1.5% remained vegetative, due to massive hemorrhage and severe neurological deficits on admission. Conclusions Despite a progress in diagnosis, CSH still remains an often cause of severe intracranial complications. The rising number of occurrences of this lesion is strictly connected with a wide use of oral anticoagulants. Surgical removal of CSH still remains the best type of treatment for such lesions.
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Affiliation(s)
- Zbigniew Kotwica
- Department of Neurosurgery, Faculty of Health Sciences and Physical Education, Kazimierz Pulaski University of Technology and Humanities, Radom, Poland
| | - Agnieszka Saracen
- Department of Neurosurgery, Faculty of Health Sciences and Physical Education, Kazimierz Pulaski University of Technology and Humanities, Radom, Poland
| | - Ireneusz Dziuba
- Department of Neurosurgery, Faculty of Health Sciences and Physical Education, Kazimierz Pulaski University of Technology and Humanities, Radom, Poland
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158
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Santos RGD, Xander PAW, Rodrigues LHDS, Costa GHFD, Veiga JCE, Aguiar GBD. Analysis of predisposing factors for chronic subdural hematoma recurrence. ACTA ACUST UNITED AC 2019; 65:834-838. [PMID: 31340313 DOI: 10.1590/1806-9282.65.6.834] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Accepted: 11/24/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVES To identify recurrence and its potential predisposing factors in a series of 595 patients with an initial diagnosis of Chronic Subdural Hematoma (CSDH) who underwent surgical treatment at a Reference Hospital of São Paulo. METHODS A retrospective descriptive study, in which the medical records of all patients with a CSDH diagnosis submitted to surgical treatment from 2000 to 2014 were analyzed. RESULTS The final study population consisted of 500 patients with a diagnosis of CSDH (95 patients with a diagnosis of Cystic Hygroma were excluded), of which 27 patients presented recurrence of the disease (5.4%). There were no statistically significant differences in relapses when cases were stratified by gender, laterality of the first episode or surgical procedure performed in the first episode (trepanning vs. craniotomy). It was possible to demonstrate an age-related protective factor, analyzed as a continuous variable, regarding the recurrence of the CSDH, with a lower rate of recurrence the higher the age. CONCLUSIONS The results indicate that, among possible factors associated with recurrence, only age presented a protective factor with statistical significance. The fact that no significant difference between the patients submitted to trepanning or craniotomy was found favors the preferential use of burr-hole surgery as a procedure of choice due to its fast and less complex execution.
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Affiliation(s)
- Rafael Gomes Dos Santos
- Resident Physician of the Neurosurgery Course at the Irmandade da Santa Casa de Misericórdia of São Paulo, São Paulo, SP, Brasil
| | - Paulo Adolfo Wessel Xander
- Resident Physician of the Neurosurgery Course at the Irmandade da Santa Casa de Misericórdia of São Paulo, São Paulo, SP, Brasil
| | | | | | - José Carlos Esteves Veiga
- Chairman and Full professor of Neurosurgery. Irmandade da Santa Casa de Misericórdia de São Paulo and Santa Casa de São Paulo School of Medicine, São Paulo, SP, Brasil
| | - Guilherme Brasileiro de Aguiar
- Assistant Physician and professor of Neurosurgery. Irmandade da Santa Casa de Misericórdia de São Paulo and Santa Casa de São Paulo School of Medicine, São Paulo, SP, Brasil
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159
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Tan LQ, Loh DDL, Qiu L, Ng YP, Hwang PYK. When hoofbeats mean zebras not horses: Tumour mimics of subdural haematoma - Case series and literature review. J Clin Neurosci 2019; 67:244-248. [PMID: 31279699 DOI: 10.1016/j.jocn.2019.06.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 05/22/2019] [Accepted: 06/21/2019] [Indexed: 11/18/2022]
Abstract
Chronic subdural haematomas are common neurosurgical conditions, especially in the elderly patients, with straightforward surgical treatments. However, infrequently, tumours are misdiagnosed as subdural haematoma on initial brain CT scans and are only discovered intraoperatively. In this case series, we presented 3 different patients who were initially thought to have subdural haematoma but later found to be tumour mimics of different histological origin. A literature review and discussion of recently published tumour mimics of subdural haematoma was also performed. It is recommended that in patients with suggestive oncological or haematological history, or unusual characteristics on the plain CT brain, a high level of suspicion of tumour mimics needs to be maintained. A full workup with contrast-enhanced magnetic resonance imaging is important to distinguish from subdural haematoma, as the treatment paradigms and prognoses are vastly different.
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Affiliation(s)
| | | | - Liming Qiu
- Department of Neurosurgery, National Neuroscience Institute, Singapore.
| | - Yew Poh Ng
- Department of Neurosurgery, National Neuroscience Institute, Singapore
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160
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Duy LA, Small JE. Subdural Hemorrhage and Posttraumatic Hygroma. Neuroradiology 2019. [DOI: 10.1016/b978-0-323-44549-8.00002-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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161
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Tomita Y, Yamada SM, Yamada S, Matsuno A. Subdural Tension on the Brain in Patients with Chronic Subdural Hematoma Is Related to Hemiparesis but Not to Headache or Recurrence. World Neurosurg 2018; 119:e518-e526. [PMID: 30075268 DOI: 10.1016/j.wneu.2018.07.192] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Revised: 07/21/2018] [Accepted: 07/23/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Hemiparesis is a major symptom of chronic subdural hematoma (CSDH). Its severity does not always correlate with hematoma size. The authors analyzed hematoma thickness, pressure, and tension to clarify the mechanism of hemiparesis in CSDH patients. METHODS A burr-hole surgery was performed on 124 CSDHs in 102 patients. Hematoma thickness and midline shift were measured by computed tomography, and hematoma pressure was measured in surgery. According to Laplace law, tension was calculated as follows: (half the hematoma thickness × hematoma pressure)/2. Student t test and Pearson correlation coefficient (r) were applied in statistical analysis of findings. RESULTS Motor weakness was identified in 76.5% of our cases. Tension was strongly related to hemiparesis (r = -0.747, P < 0.01), whereas hematoma thickness (r = -0.458, P < 0.01) and pressure (r = -0.596, P < 0.01) were moderately correlated. Mean age of 14 patients (13.7%) with headache was much younger than those without headache (P < 0.01). Stronger midline shift (P < 0.01) and greater ratio of midline shift to hematoma thickness (P < 0.01) were statistically correlated with headache. Recurrence was recognized in 8 patients (7.8%), and stronger midline shift (P < 0.05) and greater ratio of midline shift to hematoma thickness (P < 0.05) were statistically associated with recurrence. CONCLUSIONS Tension is the most influencing factor to hemiparesis in CSDH patients. This study also elucidates the mechanism for quick recovery from hemiparesis after surgery in that tension on the motor cortex is decreased immediately by drainage.
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Affiliation(s)
- Yusuke Tomita
- Department of Neurosurgery, Teikyo University Hospital Mizonokuchi, Takatsu-ku, Kawasaki, Kanagawa, Japan
| | - Shoko Merrit Yamada
- Department of Neurosurgery, Teikyo University Hospital Mizonokuchi, Takatsu-ku, Kawasaki, Kanagawa, Japan.
| | - Shokei Yamada
- Department of Neurosurgery, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Akira Matsuno
- Department of Neurosurgery, Teikyo University Medical School, Itabashi-ku, Tokyo, Japan
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162
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Scerrati A, Mangiola A, Rigoni F, Olei S, Santantonio M, Trevisi G, Anile C, Cavallo MA, De Bonis P. Do antiplatelet and anticoagulant drugs modify outcome of patients treated for chronic subdural hematoma? Still a controversial issue. J Neurosurg Sci 2018; 65:626-633. [PMID: 29671291 DOI: 10.23736/s0390-5616.18.04311-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Anticoagulants(ACs) and antiplatelet aggregation agents(AAAs) seem to be correlated to a higher incidence of chronic subdural hematoma(CSDH) but whether or not they contribute to its recurrence is debated. Few data are available on clinical outcomes and indications for the management of this therapy are not so well defined. We investigated the role of ACs and AAAs in modifying patients clinical outcomes treated for CSDH, especially for re-bleedings. METHODS This retrospective study, enrolled patients treated for CSDH. Patients characteristics were recorded including drugs used (antiplatelet/anticoagulant) and clinical conditions (Modified Rankin Scale-mRS) upon admission. Patients underwent surgery(burrhole vs minicraniectomy) with subdural drainage positioning. Clinical/radiological follow-ups were performed at one and six months. Chi square/Fisher exact test were used to compare variables and stepwise backward logistic regression analysis was used for defining their impact on complications, risk of re-bleeding and reoperation. RESULTS 230 patients (45 on ACs, 76 on AAAs and 9 on both)were enrolled. Higher mRS scores were significantly associated with a higher risk of general complications (OR = 3.78, CI 95% 1.66- 8.62, p=0.002), higher risk of rebleeding (OR =15.82, CI 95% 4.33-57.90, p <0.001) and re- operation (OR=11.39, CI 95% 3.35-37.56, p<0.0001). No statistically significant association was found between AAAs or ACs and complications or re- bleedings or risk of reoperation. CONCLUSIONS AAAs and ACs alone do not seem to worsen the clinical outcome or increase re- bleedings. mRS may be a predicting factor, since patients with higher scores showed a worse outcome and an increased risk of re-bleeding, general complications and reoperation.
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Affiliation(s)
- Alba Scerrati
- Neurosurgery, Sant'Anna University Hospital, Ferrara, Italy -
| | - Annunziato Mangiola
- Neurosurgery, Chieti University G. D'Annunzio, Santo Spirito Hospital, Pescara, Italy.,Neurotrauma, Catholic University School of Medicine, Rome, Italy
| | | | - Simone Olei
- Neurosurgery, Sant'Anna University Hospital, Ferrara, Italy
| | | | - Gianluca Trevisi
- Neurotrauma, Catholic University School of Medicine, Rome, Italy
| | - Carmelo Anile
- Neurotrauma, Catholic University School of Medicine, Rome, Italy
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163
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Wu X, Li G, Zhao J, Zhu X, Zhang Y, Hou K. Arachnoid Cyst–Associated Chronic Subdural Hematoma: Report of 14 Cases and a Systematic Literature Review. World Neurosurg 2018; 109:e118-e130. [DOI: 10.1016/j.wneu.2017.09.115] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 09/17/2017] [Accepted: 09/18/2017] [Indexed: 12/31/2022]
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164
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Hou K, Zhu X, Zhao J, Zhang Y, Gao X, Jiang K, Li G. Efficacy of Reinforced Restriction of Physical Activity on Chronic Subdural Hematoma: Prospective Pilot Study. World Neurosurg 2017; 110:e1011-e1016. [PMID: 29223519 DOI: 10.1016/j.wneu.2017.11.155] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Revised: 11/24/2017] [Accepted: 11/27/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Chronic subdural hematoma (CSDH) is a common entity in neurosurgical practice. However, as a result of the high rate in recurrence, morbidity, and mortality for surgical management, conservative management of CSDH is emerging as a new treatment strategy. Head trauma is a known risk factor of CSDH and plays as an initiator in the genesis of CSDH. We hypothesized that physical activity might also play an important role in the progression of an asymptomatic CSDH. METHODS A prospective pilot study aiming to evaluate the efficacy of reinforced restriction of physical activity for the management of asymptomatic or mild symptomatic CSDH was conducted. Twenty-six patients were enrolled in this study. RESULTS All 26 patients experienced complete resolution of the CSDH ranging from 32 to 182 days (73.1 ± 19.6 days) since the initiation of reinforced restriction of physical activity. Ages ranged from 43 to 84 years old (64.4 ± 9.6 years). No patient experienced recurrence of CSDH during the follow-up. CONCLUSIONS According to our study, physical activity might play a role in the progression of CSDH. Further prospective randomized controlled study is warranted in stable patients without evident intracranial hypertension and impending cerebral herniation.
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Affiliation(s)
- Kun Hou
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Xiaobo Zhu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Jinchuan Zhao
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Yang Zhang
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Xianfeng Gao
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Kai Jiang
- Department of Neurosurgery, The Second People's Hospital of Tonghua, Tonghua, Jilin, China
| | - Guichen Li
- Department of Neurology, The First Hospital of Jilin University, Changchun, Jilin, China.
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Management of residual subdural hematoma after burr-hole evacuation. The role of fluid therapy and review of the literature. J Clin Neurosci 2017; 46:26-29. [PMID: 28887078 DOI: 10.1016/j.jocn.2017.08.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 08/15/2017] [Indexed: 10/18/2022]
Abstract
A vast amount of literature has been published investigating the factors associated to the recurrence of a chronic subdural hematoma (SDH). However, little exists in the literature about the best medical management of the residual SDH in order to prevent the recurrence. Moreover only few studies quantitatively assess clinical and radiological outcomes of residual post-operative SDH. In this study, to our knowledge, we report the first series of chronic SDH with a quantitative outcomes analysis of the effects of fluid therapy on residual post-operative SDH. Moreover we discuss the pertinent literature. We reviewed clinical and outcome data of 39 patients (44 SDH; 12 F, 27 M) submitted to a burr-hole evacuation of a SDH. The mean age was 76.97±7.77years. All patients had a minimum 3-month follow-up (FU). Post-operatively, an intravenous saline solution was started in all cases (2000ml in 24h) and administered for 3days. Then an oral hydration with 2l per day of water was started and continued as outpatients. Glasgow Coma Scale (GCS), Karnofsky Performance Status (KPS), SDH volume and midline shift were evaluated pre-operatively, post-operatively and at FU. We found a statistically significant improvement of post-operative and at FU GCS and KPS compared to the pre-operative. SDH volume and midline shift were also statistically significant reduced in the post-operative and at FU. No complication occurred. Only 1 patient required a reoperation at 3months FU for neurological worsening. Oral fluid therapy is a safe and effective treatment for residual SDH.
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166
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Mahmood SD, Waqas M, Baig MZ, Darbar A. Mini-Craniotomy Under Local Anesthesia for Chronic Subdural Hematoma: An Effective Choice for Elderly Patients and for Patients in a Resource-Strained Environment. World Neurosurg 2017; 106:676-679. [PMID: 28735131 DOI: 10.1016/j.wneu.2017.07.057] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 07/09/2017] [Accepted: 07/11/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND Mini-craniotomy for chronic subdural hematoma (CSDH) is associated with lower rates of recurrence. However, the procedure is performed mostly with the patient under general anesthesia (GA) and therefore frequently requires an intensive care unit (ICU) facility, especially in the elderly population. Because of the unavailability of ICU beds, and to avoid GA, we started to perform this procedure with the patient under local anesthesia (LA). MATERIALS AND METHODS This was a retrospective medical chart review conducted in the section of Neurosurgery at the Aga Khan Hospital in Karachi, Pakistan. The study duration was 1 year. We included patients aged 55 years or older undergoing surgery for CSDH. Clinical characteristics, hospital stay, and recurrence rates were compared between 2 groups, local versus general anesthesia. RESULTS Thirty-five patients underwent mini-craniotomy for CSDH in the study period. Sixteen patients underwent mini-craniotomy under LA versus 19 patients for GA. Median age for the LA group was 67 years compared with 70 years in the GA group. Four patients from the LA group experienced postoperative complications versus 7 from the GA group. Only one patient in the LA group required an ICU bed in the postoperative period. There was no recurrence in LA group. The overall recurrence was 2.86%. CONCLUSIONS Mini-craniotomy for CSDH under LA is an equally effective procedure compared with mini-craniotomy under GA. In addition, it minimizes the risks of GA in the elderly population and obviates the need of a postoperative ICU bed. It also reduces operative time and hospital stay as compared with GA.
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Affiliation(s)
| | - Muhammad Waqas
- Section of Neurosurgery, Division of Surgery, The Aga Khan University Hospital, Karachi, Pakistan
| | - Mirza Zain Baig
- Medical College, The Aga Khan University Hospital, Karachi, Pakistan
| | - Aneela Darbar
- Section of Neurosurgery, Division of Surgery, The Aga Khan University Hospital, Karachi, Pakistan.
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167
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Detection of unexpected emergency diseases using FDG-PET/CT in oncology patients. Jpn J Radiol 2017; 35:539-545. [PMID: 28674772 DOI: 10.1007/s11604-017-0664-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Accepted: 06/22/2017] [Indexed: 12/18/2022]
Abstract
PURPOSE To evaluate the frequency of emergency diseases that were detected unexpectedly using FDG-PET/CT. MATERIALS AND METHODS Interpretation reports for 11,663 FDG-PET/CT studies in our hospital were retrospectively reviewed. Patients with major emergency diseases were extracted according to the following exclusion criteria: (1) relevant findings had been recognized prior to the PET/CT; (2) an intervention or operation that may have been relevant to the present findings was performed within 1 month prior to the PET/CT; and (3) the clinical course could not be investigated sufficiently (e.g., in cases where the patients were introduced from other hospitals). RESULTS Forty-one patients (0.35%) with unexpected emergency diseases were identified. The most frequent disease was pneumothorax (8 patients), followed by chronic subdural hematoma (CSH) (7 patients), ureteral stone (7 patients), and abdominal aortic aneurysm (AAA) with a dirty fat sign or a high-attenuation crescent sign visualized on CT (4 patients). Nine patients (2 pneumothorax, 3 CSH, 1 cerebral hemorrhage, 1 acute cholecystitis, 1 acute pancreatitis, and 1 acute appendicitis) were hospitalized and/or underwent therapeutic intervention within 1 week after the PET/CT. CONCLUSION Although rare, an unexpected emergency disease requiring urgent management can be detected using FDG-PET/CT in oncology patients.
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