201
|
You CG, Zheng XS. Postoperative pneumocephalus increases the recurrence rate of chronic subdural hematoma. Clin Neurol Neurosurg 2019; 166:56-60. [PMID: 29408774 DOI: 10.1016/j.clineuro.2018.01.029] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 01/23/2018] [Indexed: 12/28/2022]
Abstract
OBJECTIVES Pneumocephalus is a common operative complication of chronic subdural hematoma. This study is to analyze the relationship between postoperative pneumocephalus and the recurrence and surgical outcomes. PATIENTS AND METHODS This is a retrospective case-cohort study, including a pneumocephalus group (n = 46) and a control group (n = 181). Their recurrence rates, CT attenuation values, hospital stay, healing time and the neurological status were recorded and analyzed. RESULTS The pneumocephalus group had a recurrence rate of 32.6%, significantly higher than the control (17.7%). In addition, the pneumocephalus group had a higher rate of postoperative epilepsy (21.7% vs 3.3%), longer hospital stay (11.5 ± 2.8 vs 7.8 ± 1.2 days), longer healing time (10.8 ± 5.4 vs 6.5 ± 2.3 months), and worse neurological scores than the control. CONCLUSION Pneumocephalus increases the recurrence rate of chronic subdural hematoma, and it not only prolongs the hospital stay and healing time, but also leads to deterioration of the neurological status.
Collapse
Affiliation(s)
- Chao-Guo You
- Department of Neurosurgery, Xinhua Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xue-Sheng Zheng
- Department of Neurosurgery, Xinhua Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| |
Collapse
|
202
|
Soleman J, Lutz K, Schaedelin S, Kamenova M, Guzman R, Mariani L, Fandino J. Subperiosteal vs Subdural Drain After Burr-Hole Drainage of Chronic Subdural Hematoma: A Randomized Clinical Trial (cSDH-Drain-Trial). Neurosurgery 2019; 85:E825-E834. [DOI: 10.1093/neuros/nyz095] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 02/26/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
The use of a subdural drain (SDD) after burr-hole drainage of chronic subdural hematoma (cSDH) reduces recurrence at 6 mo. Subperiosteal drains (SPDs) are considered safer, since they are not positioned in direct contact to cortical structures, bridging veins, or hematoma membranes.
OBJECTIVE
To investigate whether the recurrence rate after insertion of a SPD is noninferior to the insertion of a more commonly used SDD.
METHODS
Multicenter, prospective, randomized, controlled, noninferiority trial analyzing patients undergoing burr-hole drainage for cSDH aged 18 yr and older. After hematoma evacuation, patients were randomly assigned to receive either a SDD (SDD-group) or a SPD (SPD-group). The primary endpoint was recurrence indicating a reoperation within 12 mo, with a noninferiority margin of 3.5%. Secondary outcomes included clinical and radiological outcome, morbidity and mortality rates, and length of stay.
RESULTS
Of 220 randomized patients, all were included in the final analysis (120 SPD and 100 SDD). Recurrence rate was lower in the SPD group (8.33%, 95% confidence interval [CI] 4.28-14.72) than in the SDD group (12.00%, 95% CI 6.66-19.73), with the treatment difference (3.67%, 95% CI -12.6-5.3) not meeting predefined noninferiority criteria. The SPD group showed significantly lower rates of surgical infections (P = .0406) and iatrogenic morbidity through drain placement (P = .0184). Length of stay and mortality rates were comparable in both groups.
CONCLUSION
Although the noninferiority criteria were not met, SPD insertion led to lower recurrence rates, fewer surgical infections, and lower drain misplacement rates. These findings suggest that SPD may be warranted in routine clinical practice
Collapse
Affiliation(s)
- Jehuda Soleman
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
| | - Katharina Lutz
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Sabine Schaedelin
- Clinical Trial Unit, University Hospital of Basel, Basel, Switzerland
| | - Maria Kamenova
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
| | - Raphael Guzman
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
| | - Luigi Mariani
- Department of Neurosurgery, University Hospital of Basel, Basel, Switzerland
| | - Javier Fandino
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| |
Collapse
|
203
|
Srivatsan A, Srinivasan VM, Thomas A, Burkhardt JK, Johnson JN, Kan P. Perspective on Safety and Effectiveness of Middle Meningeal Artery Embolization for Chronic Subdural Hematoma. World Neurosurg 2019; 127:97-98. [PMID: 30930325 DOI: 10.1016/j.wneu.2019.03.210] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 03/20/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Aditya Srivatsan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | | | - Ajith Thomas
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Jeremiah N Johnson
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA.
| |
Collapse
|
204
|
Omura T, Fukushima Y, Yoshikawa G, Matsuhashi A, Sato D, Endo T, Sato K, Inoue M, Saito A, Tsutsumi K. Cerebral Hyperperfusion Syndrome After a Burr Hole Drainage Surgery for Chronic Subdural Hematoma. World Neurosurg 2019; 124:5-8. [PMID: 30610989 DOI: 10.1016/j.wneu.2018.12.100] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 12/12/2018] [Accepted: 12/13/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Although chronic subdural hematoma (CSDH) has a good prognosis after classical minimally-invasive drainage surgery, severe complications still occur at a substantial rate. Cerebral hyperperfusion syndrome (CHS), which is a common severe complication after carotid endarterectomy or carotid artery stenting for cervical carotid artery stenosis, is rare after drainage surgery for a CSDH. CASE DESCRIPTION We describe the case of an 82-year-old woman who presented with ipsilesional symptoms including contralateral hemiparesis and dysarthria, progressively worsening consciousness, and status epilepticus after a burr hole drainage surgery for CSDH. Magnetic resonance fluid-attenuated inversion recovery imaging showed diffuse subcortical low intensity in the ipsilesional hemisphere almost simultaneously with the appearance of the symptoms. Arterial spin labeling magnetic resonance perfusion imaging showed the abnormal increase of cerebral blood flow in the hemisphere. Continuous propofol administration and blood pressure management improved the symptoms. CONCLUSIONS CHS can cause severe postoperative complications after drainage surgery for CSDH. Subcortical low-intensity fluid-attenuated inversion recovery imaging is a useful investigation for early detection of CHS in CSDH, and arterial spin labeling imaging is an effective minimally-invasive modality for confirming the diagnosis.
Collapse
|
205
|
Fiorella D, Arthur AS. Middle meningeal artery embolization for the management of chronic subdural hematoma. J Neurointerv Surg 2019; 11:912-915. [DOI: 10.1136/neurintsurg-2019-014730] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 01/28/2019] [Accepted: 01/31/2019] [Indexed: 01/25/2023]
Abstract
Chronic subdural hematoma (cSDH) is one of the most common neurosurgical diagnoses in adults. The disease is fundamentally a disorder of the meningeal blood vessels, and options exist for the minimally invasive neuroendovascular management. We review the potential role for the endovascular management of cSDH within the context of a discussion of the epidemiology, pathophysiology, and conventional management of this disease.
Collapse
|
206
|
Ou Y, Dong J, Wu L, Xu L, Wang L, Liu B, Li J, Liu W. The Clinical Characteristics, Treatment, and Outcomes of Chronic Subdural Hematoma in Young Patients. World Neurosurg 2019; 125:e1241-e1246. [PMID: 30797913 DOI: 10.1016/j.wneu.2019.02.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 02/11/2019] [Accepted: 02/12/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To investigate the clinical characteristics, treatment, and outcomes of chronic subdural hematomas (CSDH) in young patients. METHODS We retrospectively reviewed young patients under 40 years of age who received diagnoses of and were surgically treated for CSDH between August 2011 and May 2017. Clinical data, computed tomographic findings, surgical outcomes, and recurrence were collected for further analysis. RESULTS A total of 101 patients (92 male; 91.1%) were analyzed. Ages ranged from 1 to 40 years (27.3 ± 10.5), and 59 (58.4%) patients had a history of recent head trauma. The most frequent symptoms were headache (86.1%) and dizziness (26.7%). A total of 60 (59.4%) patients had arachnoid cyst (AC), and 8 (7.9%) patients had ventriculoperitoneal (V-P) shunt. After burr hole drainage craniotomy, all patients experienced good outcomes, and 1 patient experienced recurrence requiring reoperation. Sixty-eight patients with AC/V-P shunts had a higher incidence of head trauma (P = 0.014), younger age at onset (P < 0.001), and lower incidence of dizziness (P = 0.013) than did those without AC/V-P shunts. Surgical recurrence rates and outcomes did not differ significantly between patients with and without AC/V-P shunts. CONCLUSIONS Headache is the most common symptom, and AC/V-P shunts are risk factors of CSDH in young patients. AC/V-P shunt-associated CSDH is associated with younger morbidity. Head trauma is a risk factor for AC/V-P shunt-associated CSDH, but is not significance in patients without AC/V-P shunts. Catheter drainage through a burr hole may be the first-choice surgical procedure in treatment of CSDH in young patients, including AC/V-P shunt-associated CSDH.
Collapse
Affiliation(s)
- Yunwei Ou
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Beijing Neurosurgical Institute, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jinqian Dong
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Liang Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Long Xu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Lei Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Baiyun Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Jingsheng Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Weiming Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China; Neurological Center, Ningxia People's Hospital, Ningxia, China.
| |
Collapse
|
207
|
Kamenova M, Mueller C, Coslovsky M, Guzman R, Mariani L, Soleman J. Low-dose aspirin and burr-hole drainage of chronic subdural hematoma: study protocol for a randomized controlled study. Trials 2019; 20:70. [PMID: 30665464 PMCID: PMC6341728 DOI: 10.1186/s13063-018-3064-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 11/20/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Low-dose acetylsalicylic acid (ASA) in patients with chronic subdural hematoma (cSDH) represents a significant neurosurgical challenge. While continuation of ASA during the perioperative phase might increase recurrence and bleeding rates, discontinuation increases the risk of thromboembolic events. The aim of this study is to compare the postoperative recurrence and cardiovascular complication rates of patients undergoing burr-hole trepanation for cSDH with and without discontinuation of ASA. METHODS In this prospective randomized, placebo-controlled, double-blinded study we include all patients undergoing burr-hole drainage of cSDH who are under ASA treatment. The patients are randomized into two groups, one receiving ASA and the other placebo perioperatively. The study primarily seeks to compare the rate of recurrent events under ASA to that under placebo treatment. Secondary objectives are thromboembolic event rate, perioperative blood loss, postoperative anemia, intra- and postoperative blood transfusion rate, and clinical outcome. DISCUSSION To date, there is no evidence-based consensus on how to manage patients undergoing burr-hole drainage for cSDH who are under ASA treatment. Therefore, the decision to maintain or interrupt ASA treatment is based mostly on the surgeons' preference. A randomized placebo-controlled study for this frequent question is urgently needed in order to provide class I evidence for the best possible treatment of this large group of patients. TRIAL REGISTRATION ClinicalTrials.gov: NCT03120182 . Initial Release: 19.04.2017. STUDY PROTOCOL V2_23.02.2017.
Collapse
Affiliation(s)
- Maria Kamenova
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4053 CH, Basel, Switzerland.
| | - Christian Mueller
- Department of Cardiology, University Hospital of Basel, Petersgraben 4, 4031 CH, Basel, Switzerland
| | - Michael Coslovsky
- Clinical Trial Unit University Hospital of Basel, Spitalstrasse 12, 4031 CH, Basel, Switzerland
| | - Raphael Guzman
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4053 CH, Basel, Switzerland
| | - Luigi Mariani
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4053 CH, Basel, Switzerland
| | - Jehuda Soleman
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4053 CH, Basel, Switzerland
| |
Collapse
|
208
|
Lee KB, Yoon SC, Kim JS, Hong BY, Park JG, Sung WJ, Park HJ, Lim SH. Delayed Extensive White Matter Injury Caused by a Subdural Hemorrhage and Role of Corticospinal Tract Integrity. BRAIN & NEUROREHABILITATION 2019. [DOI: 10.12786/bn.2019.12.e15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Kyoung Bo Lee
- Department of Rehabilitation Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sang Cheol Yoon
- Department of Rehabilitation Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Joon Sung Kim
- Department of Rehabilitation Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Bo Young Hong
- Department of Rehabilitation Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jung Geun Park
- Department of Rehabilitation Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Won Jin Sung
- Department of Rehabilitation Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hye Jung Park
- Department of Rehabilitation Medicine, National Traffic Injury Rehabilitation Hospital, Yangpyeong, Korea
| | - Seong Hoon Lim
- Department of Rehabilitation Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| |
Collapse
|
209
|
Chronic Subdural Haematoma. Neurosurgery 2019. [DOI: 10.1007/978-3-319-98234-2_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
|
210
|
Lee KS. How to Treat Chronic Subdural Hematoma? Past and Now. J Korean Neurosurg Soc 2018; 62:144-152. [PMID: 30486622 PMCID: PMC6411568 DOI: 10.3340/jkns.2018.0156] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 07/16/2018] [Indexed: 11/27/2022] Open
Abstract
Treatment of chronic subdural hematoma (CSDH) is relatively straightforward, however, there is still some debate regarding the best strategy for treatment. The most practical recommendations of up to date were identified by a review of literature. The author reviewed the literature on CSDH management from the past to now to identify the best methods. Till 1970s, craniotomy was the most commonly used method. Burr hole (BH) became the most preferred method from 1980s. In 1977, twist drill (TD) craniostomy was introduced. Closed system drainage after a BH or a TD became the most frequently used surgical method. Although nonsurgical treatment is often successful, trephination has more advantages, such as rapid resolution of the symptoms and short period of hospitalization. Nonsurgical treatment is possible in asymptomatic patients with a small CSDH. For the symptomatic patients with CSDH, trephination is the treatment of choice, either by BH or TD. In gray zone between surgery and medical treatment, shared decision making can be an ideal approach. For the recurrent CSDHs, repeated trephination is still effective for patients with a low risk of recurrence. If the risk of recurrence is high, additional management would be helpful. For the refractory CSDHs, it is necessary to obliterate the subdural space.
Collapse
Affiliation(s)
- Kyeong-Seok Lee
- Department of Neurosurgery, Soonchunhyang University Chonan Hospital, Chonan, Korea
| |
Collapse
|
211
|
A retrospective analysis of chronic subdural haematoma recurrence rates following burr hole trephination versus minicraniotomy. J Clin Neurosci 2018; 59:47-50. [PMID: 30487056 DOI: 10.1016/j.jocn.2018.11.009] [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: 03/12/2018] [Revised: 09/16/2018] [Accepted: 11/04/2018] [Indexed: 11/24/2022]
Abstract
The aim of this study was to determine the subdural haematoma recurrence rate in patients with symptomatic chronic subdural haematomas (CSDH) treated with either burr hole trephination (BHT) or minicraniotomy (MC) and to determine whether a statistically significant difference exists between the two techniques. A retrospective analysis of all consecutive patients with symptomatic CSDH treated with BHT or MC at the John Hunter Hospital Neurosurgery Department between July 2004 and July 2016 was performed. After inclusion/exclusion criteria were applied, 368 patients with 439 CSDHs were eligible. Baseline demographic data was recorded for all patients. Statistical analysis was performed assessing haematoma recurrence as the primary outcome and mortality as a secondary outcome. Three hundred and sixty eight patients were included in the study, with 225 being treated with MC and 143 with BHT. Baseline demographic data was similar between the two groups. The recurrence rate for patients treated with BHT was 0.13 (95% CI 0.08-0.18), versus 0.18 (95% CI 0.13-0.23) in the MC group. This difference was not statistically significant. Similarly, there was no statistically significant difference in mortality rates between the two groups. The mortality rate in the BHT group was 0.09 (95% CI 0.05-0.14) versus 0.09 (95% CI 0.05-0.13) in the MC group. In our series there was no difference in recurrence rates or mortality rates between the two groups, suggesting MC is an effective alternative to BHT in the management of symptomatic CSDH.
Collapse
|
212
|
Link TW, Boddu S, Paine SM, Kamel H, Knopman J. Middle Meningeal Artery Embolization for Chronic Subdural Hematoma: A Series of 60 Cases. Neurosurgery 2018; 85:801-807. [DOI: 10.1093/neuros/nyy521] [Citation(s) in RCA: 102] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 10/02/2018] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
Chronic subdural hematoma (SDH) is a particularly challenging pathology due to high recurrence rates (2%-37%) and complex medical comorbidities that tend to afflict the patient population. Recently, there have been several case series published describing the use of middle meningeal artery (MMA) embolization as an alternative to surgery for treatment of new or recurrent chronic SDH.
OBJECTIVE
To describe our first 60 cases of MMA embolization for chronic SDH.
METHODS
MMA embolization was performed using angiography, selective microcatheterization of the MMA, and infusion of polyvinyl alcohol particles. Outcomes were assessed clinically and with interval imaging studies at 1 d, 2 wk, and 6 wk postprocedure, and additional intervals as indicated.
RESULTS
MMA embolization was performed successfully on 60 total SDHs in 49 patients. This includes upfront treatment for new (not previously treated) SDH in 42, for recurrence in 8, and prophylaxis (soon after surgical evacuation) in 10. There were 3 mortalities (unrelated to the procedure), and no procedural complications. Of the 50 nonprophylactic cases, there were 4 (8.9%) cases of recurrence requiring surgical evacuation, and 31 (68.9%) that had resolution or reduction in size >50% of SDH at longest follow-up. Overall, 41 (91.1%) were stable or decreased in size and able to avoid surgery.
CONCLUSION
MMA embolization may represent a minimally-invasive alternative to surgery for new or recurrent chronic SDH, or as prophylaxis to reduce the risk of recurrence after surgery. Given our encouraging results with a 91% long-term success rate, a large scale clinical trial is warranted.
Collapse
Affiliation(s)
- Thomas W Link
- Department of Neurosurgery, Weill Cornell Medical Institution New York Presbyterian Hospital, New York, New York
| | - Srikanth Boddu
- Department of Neurosurgery, Weill Cornell Medical Institution New York Presbyterian Hospital, New York, New York
| | - Stephanie M Paine
- Department of Neurosurgery, Weill Cornell Medical Institution New York Presbyterian Hospital, New York, New York
| | - Hooman Kamel
- Department of Neurology, Weill Cornell Medical Institution New York Presbyterian Hospital, New York, New York
| | - Jared Knopman
- Department of Neurosurgery, Weill Cornell Medical Institution New York Presbyterian Hospital, New York, New York
| |
Collapse
|
213
|
Effects of Pre-Existing Comorbidities on Outcomes in Patients with Chronic Subdural Hematoma. World Neurosurg 2018; 122:e924-e932. [PMID: 30408607 DOI: 10.1016/j.wneu.2018.10.176] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 10/23/2018] [Accepted: 10/26/2018] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The number of patients with chronic subdural hematoma (CSDH) showing comorbidities and/or impaired activities of daily living (ADL) before the onset of CSDH has increased with the recent aging of society. The purposes of this study were to evaluate ADL worsening by comparing premorbid ADL and ADL at discharge and to investigate the effects of pre-existing comorbidity-related clinical factors on the outcomes. METHODS A total of 570 patients with CSDH admitted from 2006 to 2016 were studied retrospectively. Clinical factors, including pre-existing comorbidities, related to outcomes were identified by multivariate analysis. A variation of the modified Rankin Scale (mRS) using 5 united categories of mRS scores 0/1, 2, 3/4, 5, and dead was used for evaluation of ADL. RESULTS Of 570 patients, 390 (68.4%) had pre-existing comorbidities and 120 (21.1%) showed premorbid impaired ADL (mRS scores 2 and worse). Considering pre-existing impaired ADL, ADL deteriorated after CSDH in 92 patients (16.1%), whereas ADL impairment at discharge was found in 173 patients (30.4%). Comorbidities related to ADL deterioration on multivariate analysis were hemodialysis and chronic heart failure. Antithrombotic use for cardiovascular diseases was a predictor of acute-on-chronic subdural hematoma, which was the sole common predictor for ADL deterioration and the occurrence of surgical complications. CONCLUSIONS In patients with CSDH, pre-existing comorbidity-linked factors related to outcomes were hemodialysis, chronic heart failure, and antithrombotic use. Patients with acute-on-chronic subdural hematoma with these factors should be regarded as a high-risk group.
Collapse
|
214
|
Motiei-Langroudi R, Stippler M, Shi S, Adeeb N, Gupta R, Griessenauer CJ, Papavassiliou E, Kasper EM, Arle J, Alterman RL, Ogilvy CS, Thomas AJ. Factors predicting reoperation of chronic subdural hematoma following primary surgical evacuation. J Neurosurg 2018; 129:1143-1150. [PMID: 29243977 DOI: 10.3171/2017.6.jns17130] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 06/05/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVEChronic subdural hematoma (CSDH) is commonly encountered in neurosurgical practice. However, surgical evacuation remains complicated by a high rate of reoperation. The optimal surgical approach to reduce the reoperation rate has not been determined. In the current study, the authors evaluated the prognostic value of clinical and radiographic factors to predict reoperation in the context of CSDH.METHODSA retrospective review of 325 CSDH patients admitted to an academic medical center in the United States, between 2006 and 2016, was performed. Clinical and radiographic factors predictive of the need for CSDH reoperation were identified on univariable and multivariable analyses.RESULTSUnivariable analysis showed that warfarin use, clopidogrel use, mixed hypo- and isointensity on T1-weighted MRI, greater preoperative midline shift, larger hematoma/fluid residual on first postoperative day CT, lesser decrease in hematoma size after surgery, use of monitored anesthesia care (MAC), and lack of intraoperative irrigation correlated with a significantly higher rate of reoperation. Multivariable analysis, however, showed that only the presence of loculation, clopidogrel or warfarin use, and percent of hematoma change after surgery significantly predicted the need for reoperation. Our results showed that 0% (no reduction), 50%, and 100% hematoma maximum thickness change (complete resolution of hematoma after surgery) were associated with a 41%, 6%, and < 1% rate of reoperation, respectively. The use of drains, either large diameter or small caliber, did not have any effect on the likelihood of reoperation.CONCLUSIONSAmong many factors, clopidogrel or warfarin use, hematoma loculation on preoperative CT, and the amount of hematoma evacuation on the first postoperative CT were the strongest predictors of reoperation.
Collapse
|
215
|
Miah IP, Holl DC, Peul WC, Walchenbach R, Kruyt N, de Laat K, Koot RW, Volovici V, Dirven CMF, van Kooten F, Kho KH, den Hertog HM, van der Naalt J, Jacobs B, Groen RJM, Lingsma HF, Dammers R, Jellema K, van der Gaag NA. Dexamethasone therapy versus surgery for chronic subdural haematoma (DECSA trial): study protocol for a randomised controlled trial. Trials 2018; 19:575. [PMID: 30342554 PMCID: PMC6196013 DOI: 10.1186/s13063-018-2945-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Accepted: 09/26/2018] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Chronic subdural haematoma (CSDH) is a common neurological disease with a rapidly rising incidence due to increasing age and widespread use of anticoagulants. Surgical intervention by burr-hole craniotomy (BHC) is the current standard practice for symptomatic patients, but associated with complications, a recurrence rate of up to 30% and increased mortality. Dexamethasone (DXM) therapy is, therefore, used as a non-surgical alternative but considered to achieve a lower success rate. Furthermore, the benefit of DXM therapy appears much more deliberate than the immediate relief from BHC. Lack of evidence and clinical equipoise among caregivers prompts the need for a head-to-head randomised controlled trial. The objective of this study is to compare the effect of primary DXM therapy versus primary BHC on functional outcome and cost-effectiveness in symptomatic patients with CSDH. METHODS/DESIGN This study is a prospective, multicentre, randomised controlled trial (RCT). Consecutive patients with a CSDH with a Markwalder Grading Scale (MGS) grade 1 to 3 will be randomised to treatment with DXM or BHC. The DXM treatment scheme will be 16 mg DXM per day (8 mg twice daily, days 1 to 4) which is then halved every 3 days until a dosage of 0.5 mg a day on day 19 and stopped on day 20. If the treatment response is insufficient (i.e. persistent or progressive symptomatology due to insufficient haematoma resolution), additional surgery can be performed. The primary outcomes are the functional outcome by means of the modified Rankin Scale (mRS) score at 3 months and cost-effectiveness at 12 months. Secondary outcomes are quality of life at 3 and 12 months using the Short Form Health Survey (SF-36) and Quality of Life after Brain Injury Overall Scale (QOLIBRI), haematoma thickness after 2 weeks on follow-up computed tomography (CT), haematoma recurrence during the first 12 months, complications and drug-related adverse events, failure of therapy within 12 months after randomisation and requiring intervention, mortality during the first 3 and 12 months, duration of hospital stay and overall healthcare and productivity costs. To test non-inferiority of DXM therapy compared to BHC, 210 patients in each treatment arm are required (assumed adjusted common odds ratio DXM compared to BHC 1.15, limit for inferiority < 0.9). The aim is to include a total of 420 patients in 3 years with an enrolment rate of 60%. DISCUSSION The present study should demonstrate whether treatment with DXM is as effective as BHC on functional outcome, at lower costs. TRIAL REGISTRATION EUCTR 2015-001563-39 . Date of registration: 29 March 2015.
Collapse
Affiliation(s)
- Ishita P. Miah
- Department of Neurology and Neurosurgery, Haaglanden Medical Centre (HMC), Lijnbaan 32, 2512 VA The Hague, The Netherlands
| | - Dana C. Holl
- Department of Neurology and Neurosurgery, Erasmus Medical Centre (EMC), Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Wilco C. Peul
- Department of Neurology and Neurosurgery, Haaglanden Medical Centre (HMC), Lijnbaan 32, 2512 VA The Hague, The Netherlands
- Department of Neurology and Neurosurgery, Leiden University Medical Centre (LUMC), Albinusdreef 2, 2333 ZA Leiden, The Netherlands
- Department of Neurology and Neurosurgery, Haga Teaching Hospital, Els Borst-Eilersplein 275, 2545 AA The Hague, The Netherlands
| | - Robert Walchenbach
- Department of Neurology and Neurosurgery, Haaglanden Medical Centre (HMC), Lijnbaan 32, 2512 VA The Hague, The Netherlands
| | - Nyika Kruyt
- Department of Neurology and Neurosurgery, Leiden University Medical Centre (LUMC), Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Karlijn de Laat
- Department of Neurology and Neurosurgery, Haga Teaching Hospital, Els Borst-Eilersplein 275, 2545 AA The Hague, The Netherlands
| | - Radboud W. Koot
- Department of Neurology and Neurosurgery, Leiden University Medical Centre (LUMC), Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Victor Volovici
- Department of Neurology and Neurosurgery, Erasmus Medical Centre (EMC), Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Clemens M. F. Dirven
- Department of Neurology and Neurosurgery, Erasmus Medical Centre (EMC), Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Fop van Kooten
- Department of Neurology and Neurosurgery, Erasmus Medical Centre (EMC), Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Kuan H. Kho
- Department of Neurosurgery, Medisch Spectrum Twente (MST), Koningsplein 1, 7512 KZ Enschede, The Netherlands
| | - Heleen M. den Hertog
- Department of Neurology, Isala Hospital Zwolle, Dokter van Heesweg 2, 8025 AB Zwolle, The Netherlands
| | - Joukje van der Naalt
- Department of Neurology and Neurosurgery, University of Groningen, University Medical Centre Groningen (UMCG), Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Bram Jacobs
- Department of Neurology and Neurosurgery, University of Groningen, University Medical Centre Groningen (UMCG), Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Rob J. M. Groen
- Department of Neurology and Neurosurgery, University of Groningen, University Medical Centre Groningen (UMCG), Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Hester F. Lingsma
- Department of Public Health, Erasmus Medical Centre (EMC), Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Ruben Dammers
- Department of Neurology and Neurosurgery, Erasmus Medical Centre (EMC), Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Korné Jellema
- Department of Neurology and Neurosurgery, Haaglanden Medical Centre (HMC), Lijnbaan 32, 2512 VA The Hague, The Netherlands
| | - Niels A. van der Gaag
- Department of Neurology and Neurosurgery, Haaglanden Medical Centre (HMC), Lijnbaan 32, 2512 VA The Hague, The Netherlands
- Department of Neurology and Neurosurgery, Leiden University Medical Centre (LUMC), Albinusdreef 2, 2333 ZA Leiden, The Netherlands
- Department of Neurology and Neurosurgery, Haga Teaching Hospital, Els Borst-Eilersplein 275, 2545 AA The Hague, The Netherlands
| | - on behalf of the Dutch Subdural Hematoma Research Group (DSHR)
- Department of Neurology and Neurosurgery, Haaglanden Medical Centre (HMC), Lijnbaan 32, 2512 VA The Hague, The Netherlands
- Department of Neurology and Neurosurgery, Erasmus Medical Centre (EMC), Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
- Department of Public Health, Erasmus Medical Centre (EMC), Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
- Department of Neurology and Neurosurgery, Leiden University Medical Centre (LUMC), Albinusdreef 2, 2333 ZA Leiden, The Netherlands
- Department of Neurology and Neurosurgery, Haga Teaching Hospital, Els Borst-Eilersplein 275, 2545 AA The Hague, The Netherlands
- Department of Neurosurgery, Medisch Spectrum Twente (MST), Koningsplein 1, 7512 KZ Enschede, The Netherlands
- Department of Neurology, Isala Hospital Zwolle, Dokter van Heesweg 2, 8025 AB Zwolle, The Netherlands
- Department of Neurology and Neurosurgery, University of Groningen, University Medical Centre Groningen (UMCG), Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| |
Collapse
|
216
|
Link TW, Schwarz JT, Paine SM, Kamel H, Knopman J. Middle Meningeal Artery Embolization for Recurrent Chronic Subdural Hematoma: A Case Series. World Neurosurg 2018; 118:e570-e574. [DOI: 10.1016/j.wneu.2018.06.241] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 06/27/2018] [Accepted: 06/28/2018] [Indexed: 11/30/2022]
|
217
|
Chmieliauskas S, Anuzyte JS, Liucvaikyte J, Laima S, Jurolaic E, Rocka S, Fomin D, Stasiuniene J, Jasulaitis A. Importance of effusion of blood under the dura mater in forensic medicine: A STROBE - compliant retrospective study. Medicine (Baltimore) 2018; 97:e12567. [PMID: 30278562 PMCID: PMC6181611 DOI: 10.1097/md.0000000000012567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Subdural hemorrhage is commonly associated with mechanical brain injury and has a correspondingly high mortality rate. Subdural hematomas may immediately provoke symptoms or may be initially asymptomatic, with further symptoms evolving rapidly and fatally.The data regarding forensic autopsy of victims were obtained from The State Forensic Medicine Service of Lithuania between the years 2013 and 2016. A retrospective study was performed including 110 patients, whose cause of death was subdural hemorrhage. 95% confidence intervals were calculated.It was calculated, that in cases of sudden death, after subdural hemorrhage was diagnosed, a higher concentration of ethyl alcohol in blood (mean 2.22 ± 1.3%) demanded a smaller amount of blood under the dura matter (mean 81.6 ± 60.5 g) in order for the patient to die. It was also noted that hospitalized patients with subdural hemorrhage had a smaller concentration of blood ethyl alcohol (mean 1.33 ± 1%) and a larger amount of blood under the dura (mean 135.6 ± 82.9 g).Due to the toxic effect of ethyl alcohol, even a small amount (81.6 ± 60.5 g) of blood under the dura matter can determine a sudden death.
Collapse
Affiliation(s)
- Sigitas Chmieliauskas
- Department of Pathology, Forensic Medicine and Pharmacology, Institute of Biomedical Sciences of the Faculty of Medicine of Vilnius University
- State Forensic Medicine Service
| | - Joginte Saule Anuzyte
- Department of Pathology, Forensic Medicine and Pharmacology, Institute of Biomedical Sciences of the Faculty of Medicine of Vilnius University
| | - Julita Liucvaikyte
- Department of Pathology, Forensic Medicine and Pharmacology, Institute of Biomedical Sciences of the Faculty of Medicine of Vilnius University
| | - Sigitas Laima
- Department of Pathology, Forensic Medicine and Pharmacology, Institute of Biomedical Sciences of the Faculty of Medicine of Vilnius University
- State Forensic Medicine Service
| | | | - Saulius Rocka
- Department of Neurology and Neurosurgery, Vilnius University, Vilnius, Lithuania
| | - Dmitrij Fomin
- Department of Pathology, Forensic Medicine and Pharmacology, Institute of Biomedical Sciences of the Faculty of Medicine of Vilnius University
- State Forensic Medicine Service
| | - Jurgita Stasiuniene
- Department of Pathology, Forensic Medicine and Pharmacology, Institute of Biomedical Sciences of the Faculty of Medicine of Vilnius University
| | - Algimantas Jasulaitis
- Department of Pathology, Forensic Medicine and Pharmacology, Institute of Biomedical Sciences of the Faculty of Medicine of Vilnius University
| |
Collapse
|
218
|
Zolfaghari S, Ståhl N, Nittby Redebrandt H. Does time from diagnostic CT until surgical evacuation affect outcome in patients with chronic subdural hematoma? Acta Neurochir (Wien) 2018; 160:1703-1709. [PMID: 30043090 PMCID: PMC6105227 DOI: 10.1007/s00701-018-3620-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 07/13/2018] [Indexed: 11/24/2022]
Abstract
Background Chronic subdural hematoma (CSDH) is one of the most common neurosurgical conditions. Patients diagnosed with CSDH’s are often planned for subacute surgery. This means that time from diagnostic CT scan until actual surgery might often be prolonged. There are no previous studies that highlight the effect of delayed intervention in this population. Method Patients that underwent surgical evacuation for a CSDH at Skåne University Hospital between 1 January 2015 and 31 December 2016 were included in this retrospective cohort study (n = 179). The primary aim was to determine if time from initial diagnosis by head-CT until surgical evacuation had a significant effect on outcome. The following was assessed by mortality, re-operation, number of days spent in hospital, discharge to home/institution, and functional outcome assessed by GOS. Secondary aims were to evaluate the effect of NOAC, vitamin K antagonists, and antiplatelet drugs on time from CT to surgery and re-operation frequency. Results Mean time from diagnostic CT scan until surgery was 76 h. No significant relationship was found between time from CT to surgical evacuation and number of days spent in hospital, discharge to own home/institution, 1-year mortality, or outcome assessed by GOS at discharge from hospital. The clear majority (95.5%) of the patients were GCS ≥ 13 pre-operatively. No correlation could be seen between use of NOAC, vitamin K antagonists, or antiplatelet drugs regarding the risk for reoperation within 6 months, and no correlation between the use of these agents and time from CT to surgery. The 30-day mortality was too low to draw any statistically significant conclusions (n = 4). Conclusion In this retrospective cohort study, we could conclude that a delay from initial diagnosis confirming a CSDH to surgical evacuation had no negative effect on outcome when surgery was performed within the time frames and on patients with pre-operatively favorable GCS scores (≥ 13) outlined in our study.
Collapse
Affiliation(s)
- Shaian Zolfaghari
- The Rausing Laboratory, Division of Neurosurgery, Department of Clinical Sciences Lund, Lund University, 221 85, Lund, Sweden.
| | - Nils Ståhl
- Department of Neurosurgery, Skåne University Hospital, Lund, Sweden
| | - Henrietta Nittby Redebrandt
- The Rausing Laboratory, Division of Neurosurgery, Department of Clinical Sciences Lund, Lund University, 221 85, Lund, Sweden
- Department of Neurosurgery, Skåne University Hospital, Lund, Sweden
| |
Collapse
|
219
|
Xu C, Chen B, Xue L, Xia L, Yang X, Wei M, Hui X, Chen Q, Zheng J, Li Z, Tian X, Cheng G, Xiao F, Lu M. Randomized controlled study on the curative effects of twist-drill craniotomy and burr-hole craniotomy in the treatment of chronic subdural hematoma. Exp Ther Med 2018; 16:959-965. [PMID: 30116345 DOI: 10.3892/etm.2018.6265] [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: 11/04/2017] [Accepted: 05/02/2018] [Indexed: 11/05/2022] Open
Abstract
The present randomized controlled study investigated the differences in the curative effects of twist-drill craniotomy (TDC) and burr-hole craniotomy (BHC) in the treatment of chronic subdural hematoma (CSDH). A total of 40 patients diagnosed with CSDH via head computed tomography (CT) who required surgical decompression from January 2016 to January 2017 were enrolled in the present study, and were randomly divided into a TDC group (n=20) and a BHC group (n=20). The modified Rankin scale (mRS) scores of patients were recorded prior to the operation, and at 48 h and 3 months after the operation. The differences in the mRS score (VmRS) among the groups were calculated using the Mann-Whitney U test. The 40 patients enrolled comprised 33 males and 7 females, and there were no significant differences in the general clinical characteristics between the two groups. In the BHC group, 3 patients had a pre-operative mRS score of 5 points, among which 2 cases died at 32 and 45 days after discharge. In the TDC group, 4 patients had a pre-operative mRS score of 5 points, among which 1 case died of epilepsy and pulmonary infection at 1 month after the operation. No difference in the mortality rate was present between the two groups. During the 3-month follow-up, head CT indicated that the intracranial hematoma in a total of 4 patients, including 3 cases in the TDC group and 1 case in the BHC group, completely disappeared. In the BHC group, 3 cases required a repeated incision and drainage after the first operation, while no secondary operation was required in any of the cases of the TDC group. The average length of stay at the hospital (LOS) after TDC was 9.00±2.91 days, which was significantly shorter than that after BHC (14.75±5.95 days). In the total sample of 40 patients, a longer LOS was associated with a higher risk of secondary operation due to recurrence after discharge. The variation value of the mRS score at 3 months after the operation and its ratio vs. the pre-operative score in the TDC group were significantly different from those in the BHC group, suggesting that the improvement of neurological function after TDC was significantly greater than that after BHC. Although 18 patients (90%) in the TDC group were cured, there was no significant difference from the cure rate in the BHC group [15 patients (75%)]. In conclusion, no significant differences were identified in the cure rate and the mortality rate of patients with CSDH after the two types of surgical treatment. However, the mRS score in the TDC group at 3 months after the operation exhibited a significantly greater improvement compared with that in the BHC group, and the overall LOS in the TDC group was significantly shorter than that in BHC group. Therefore, TDC is superior to BHC in the treatment of CSDH (trial registration no. ChiCTR-INR-16008368).
Collapse
Affiliation(s)
- Changsong Xu
- Department of Neurology, Huai'an First People's Hospital, Nanjing Medical University, Huai'an, Jiangsu 223300, P.R. China
| | - Bing Chen
- Department of Neurology, Huai'an First People's Hospital, Nanjing Medical University, Huai'an, Jiangsu 223300, P.R. China
| | - Liujun Xue
- Department of Neurology, Huai'an First People's Hospital, Nanjing Medical University, Huai'an, Jiangsu 223300, P.R. China
| | - Lei Xia
- Department of Neurology, Huai'an First People's Hospital, Nanjing Medical University, Huai'an, Jiangsu 223300, P.R. China
| | - Xiu Yang
- Department of Neurology, Huai'an First People's Hospital, Nanjing Medical University, Huai'an, Jiangsu 223300, P.R. China
| | - Ming Wei
- Department of Neurology, Huai'an First People's Hospital, Nanjing Medical University, Huai'an, Jiangsu 223300, P.R. China
| | - Xiaobo Hui
- Department of Neurosurgery, Huai'an First People's Hospital, Nanjing Medical University, Huai'an, Jiangsu 223300, P.R. China
| | - Quan Chen
- Department of Neurology, Huai'an First People's Hospital, Nanjing Medical University, Huai'an, Jiangsu 223300, P.R. China
| | - Jinlong Zheng
- Department of Neurology, Huai'an First People's Hospital, Nanjing Medical University, Huai'an, Jiangsu 223300, P.R. China
| | - Zhengming Li
- Department of Neurosurgery, Huai'an First People's Hospital, Nanjing Medical University, Huai'an, Jiangsu 223300, P.R. China
| | - Xiangyang Tian
- Department of Neurology, Huai'an First People's Hospital, Nanjing Medical University, Huai'an, Jiangsu 223300, P.R. China
| | - Guanliang Cheng
- Department of Neurology, Huai'an First People's Hospital, Nanjing Medical University, Huai'an, Jiangsu 223300, P.R. China
| | - Feng Xiao
- Department of Neurology, Huai'an First People's Hospital, Nanjing Medical University, Huai'an, Jiangsu 223300, P.R. China
| | - Min Lu
- Department of Rehabilitation Medicine, Huai'an First People's Hospital, Nanjing Medical University, Huai'an, Jiangsu 223300, P.R. China
| |
Collapse
|
220
|
Iorio-Morin C, Touchette C, Lévesque M, Effendi K, Fortin D, Mathieu D. Chronic Subdural Hematoma: Toward a New Management Paradigm for an Increasingly Complex Population. J Neurotrauma 2018; 35:1882-1885. [DOI: 10.1089/neu.2018.5872] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- Christian Iorio-Morin
- Division of Neurosurgery, Department of Surgery, Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Charles Touchette
- Division of Neurosurgery, Department of Surgery, Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Mathieu Lévesque
- Division of Neurology, Department of Medicine, Université de Sherbrooke, Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Khaled Effendi
- Division of Neurosurgery, Department of Surgery, Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - David Fortin
- Division of Neurosurgery, Department of Surgery, Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - David Mathieu
- Division of Neurosurgery, Department of Surgery, Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| |
Collapse
|
221
|
Baschera D, Tosic L, Westermann L, Oberle J, Alfieri A. Treatment Standards for Chronic Subdural Hematoma: Results from a Survey in Austrian, German, and Swiss Neurosurgical Units. World Neurosurg 2018; 116:e983-e995. [DOI: 10.1016/j.wneu.2018.05.145] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 05/19/2018] [Accepted: 05/19/2018] [Indexed: 10/16/2022]
|
222
|
Yuan Y, Wang QP, Cao YL, Zhang H, Burkutally MSN, Budryte K, Xiong N. Burr hole drainage and burr hole drainage with irrigation to treat chronic subdural hematoma: A systematic review and meta-analysis. Medicine (Baltimore) 2018; 97:e11827. [PMID: 30113471 PMCID: PMC6113043 DOI: 10.1097/md.0000000000011827] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE Numerous studies have investigated different operative procedures for treating chronic subdural hematoma (CSDH); however, the results are controversial. This meta-analysis was performed to evaluate the efficacy of burr hole drainage without irrigation (BHD) and burr hole drainage with irrigation (BHDI) for CSDH. METHODS We searched the following electronic databases to identify all studies from their inception to September 2017: Cochrane Library, Science Direct, MEDLINE, EMBASE, Scopus, Google Scholar, the China Biomedical Database (CBM), and the Chinese National Knowledge Infrastructure (CNKI). Randomized clinical trials (RCTs), prospective cohort studies, retrospective observational cohort studies, and case-control studies investigating BHD and BHDI for the treatment of CSDH were included. The Cochrane Collaboration's RevMan 5.3 software was used for meta-analysis. RESULTS In total, 7 retrospective cohort studies and 2 RCTs involving 993 participants were included. Comprehensive analysis results of 9 studies indicated that the recurrence of the BHDI was similar to that in BHD (odds ratio [OR] = 1.27, 95% confidence interval [CI] = .61-2.63, P = .53). Moreover, analysis for comparing recurrence in the 2 RCTs was not significantly different (OR = 1.14, 95% CI = .16-8.24, P = .95).In addition, meta-analysis of pneumocephalus (OR = 5.91, 95% CI = .61-56.86, P = .12) and mortality (OR = 0.94, 95% CI 0.14-6.16, P = .95) was not significantly different. CONCLUSIONS The results of this meta-analysis demonstrated that procedures with or without irrigation in the treatment of CSDH might have similar effect regarding recurrence and complications; therefore, irrigation might not be necessary. However, well-conducted RCTs and high-quality observational studies are still required to corroborate this issue.
Collapse
Affiliation(s)
| | | | - Yu-lin Cao
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
| | - Hongri Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Henan University of Science and Technology, Luoyang, China
| | | | - Kamile Budryte
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | | |
Collapse
|
223
|
Stanišic M, Pripp AH. A Reliable Grading System for Prediction of Chronic Subdural Hematoma Recurrence Requiring Reoperation After Initial Burr-Hole Surgery. Neurosurgery 2018; 81:752-760. [PMID: 28379528 PMCID: PMC5808673 DOI: 10.1093/neuros/nyx090] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Accepted: 02/11/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND There is no widely adopted grading system for the prediction of postoperative recurrence requiring reoperation (RrR) in patients with chronic subdural hematoma (CSDH). OBJECTIVE We developed a CSDH grading system to predict RrR based on predictive characteristics that can be objectively assessed at the time of first presentation and initial surgery. METHODS Prospectively collected data from 107 consecutive surgical patients with CSDH were reviewed. Predictors of RrR were identified via logistic and lasso regression analyses. A prognostic CSDH grading system was proposed, with the weighing of predictors based on strength of association. The scoring system was then applied to the same set of patients in our database for internal validation. RESULTS The strongest predictors of RrR were an isodense or hyperdense lesions and laminar or separated lesions, and a postoperative CSDH cavity volume greater than 200 mL. The moderate predictors of RrR were a postoperative CSDH cavity volume of 80 to 200 mL and a preoperative CSDH volume greater than 130 mL. According to the prognostic CSDH grading system, no patients with a score of 0 points had RrR. RrR was observed in 6% of patients with a score of 1 to 2 points, 30% of patients with a score of 3 to 4 points, and 63% of patients with a score of 5 points (ie, the maximum score). The rate of RrR increased steadily with increases in the prognostic CSDH grading score (P < .001). CONCLUSION The prognostic CSDH grading system is an applicable tool for RrR risk stratification in patients with CSDH.
Collapse
Affiliation(s)
- Milo Stanišic
- Department of Neurosurgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Are Hugo Pripp
- Oslo Centre of Biostatistics and Epidemiology, Research Support Service, Oslo University Hospital, Oslo, Norway
| |
Collapse
|
224
|
Holl DC, Volovici V, Dirven CMF, Peul WC, van Kooten F, Jellema K, van der Gaag NA, Miah IP, Kho KH, den Hertog HM, Lingsma HF, Dammers R. Pathophysiology and Nonsurgical Treatment of Chronic Subdural Hematoma: From Past to Present to Future. World Neurosurg 2018; 116:402-411.e2. [PMID: 29772364 DOI: 10.1016/j.wneu.2018.05.037] [Citation(s) in RCA: 108] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Accepted: 05/05/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND Chronic subdural hematoma (CSDH) is one of the more frequent pathologic entities in daily neurosurgical practice. Historically, CSDH was considered progressive recurrent bleeding with a traumatic cause. However, recent evidence has suggested a complex intertwined pathway of inflammation, angiogenesis, local coagulopathy, recurrent microbleeds, and exudates. The aim of the present review is to collect existing data on pathophysiology of CSDH to direct further research questions aiming to optimize treatment for the individual patient. METHODS We performed a thorough literature search in PubMed, Ovid, EMBASE, CINAHL, and Google scholar, focusing on any aspect of the pathophysiology and nonsurgical treatment of CSDH. RESULTS After a (minor) traumatic event, the dural border cell layer tears, which leads to the extravasation of cerebrospinal fluid and blood in the subdural space. A cascade of inflammation, impaired coagulation, fibrinolysis, and angiogenesis is set in motion. The most commonly used treatment is surgical drainage. However, because of the pathophysiologic mechanisms, the mortality and high morbidity associated with surgical drainage, drug therapy (dexamethasone, atorvastatin, tranexamic acid, or angiotensin-converting enzyme inhibitors) might be a beneficial alternative in many patients with CSDH. CONCLUSIONS Based on pathophysiologic mechanisms, animal experiments, and small patient studies, medical treatment may play a role in the treatment of CSDH. There is a lack of level I evidence in the nonsurgical treatment of CSDH. Therefore, randomized controlled trials, currently lacking, are needed to assess which treatment is most effective in each individual patient.
Collapse
Affiliation(s)
- Dana C Holl
- Department of Neurosurgery, Erasmus Medical Center, Erasmus MC Stroke Center, Rotterdam, The Netherlands.
| | - Victor Volovici
- Department of Neurosurgery, Erasmus Medical Center, Erasmus MC Stroke Center, Rotterdam, The Netherlands; Department of Public Health and Medical Decision Making, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Clemens M F Dirven
- Department of Neurosurgery, Erasmus Medical Center, Erasmus MC Stroke Center, Rotterdam, The Netherlands
| | - Wilco C Peul
- Department of Neurosurgery, Leiden University Medical Center, Leiden, Haaglanden MC and Haga Teaching Hospital, The Hague, The Netherlands
| | - Fop van Kooten
- Department of Neurology, Erasmus Medical Center, Erasmus MC Stroke Center, Rotterdam, The Netherlands
| | - Korné Jellema
- Department of Neurology, Haaglanden Medical Center, The Hague, The Netherlands
| | - Niels A van der Gaag
- Department of Neurosurgery, Leiden University Medical Center, Leiden, Haaglanden MC and Haga Teaching Hospital, The Hague, The Netherlands
| | - Ishita P Miah
- Department of Neurology, Haaglanden Medical Center, The Hague, The Netherlands
| | - Kuan H Kho
- Department of Neurosurgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | | | - Hester F Lingsma
- Department of Public Health and Medical Decision Making, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Ruben Dammers
- Department of Neurosurgery, Erasmus Medical Center, Erasmus MC Stroke Center, Rotterdam, The Netherlands
| | | |
Collapse
|
225
|
Link TW, Rapoport BI, Paine SM, Kamel H, Knopman J. Middle meningeal artery embolization for chronic subdural hematoma: Endovascular technique and radiographic findings. Interv Neuroradiol 2018; 24:455-462. [PMID: 29720020 DOI: 10.1177/1591019918769336] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background and purpose Embolization of the middle meningeal artery (MMA) has recently been proposed as an alternative to surgery for treatment of chronic subdural hematoma (SDH), and several case reports have been published supporting its efficacy. It has been suggested that the primary pathologic process in chronic SDH is repeated microhemorrhaging into the subdural collection from fragile neovasculature within the SDH membrane that arises from distal branches of the MMA. Embolization could thus provide a means of eliminating this chronic rebleeding. Materials and methods Images were selected from MMA embolization procedures performed at our institution in order to illustrate the technique and theory behind its efficacy for treatment of chronic SDH. Results Images from MMA angiograms demonstrate the variability of MMA anatomy and help illustrate the importance of avoiding potential ophthalmic collaterals and branches supplying cranial nerves. The findings of irregular wispiness of the distal MMA vasculature, contrast outlining of the SDH membrane on angiography, and homogenous increased density within the SDH on postembolization head computed tomography are described. Conclusion MMA embolization may provide a safe alternative for treatment of chronic SDH, but careful angiographic assessment of MMA anatomy should be performed to avoid potential complications. The findings illustrated here lend support to the theory that the pathologic process of chronic SDH is repeated leakage of blood products from an inflamed, abnormal arterial neovasculature within the SDH membrane that arises from the MMA, and thus selective embolization could provide an effective treatment.
Collapse
Affiliation(s)
- Thomas W Link
- 1 Department of Neurosurgery, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Benjamin I Rapoport
- 1 Department of Neurosurgery, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Stephanie M Paine
- 1 Department of Neurosurgery, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Hooman Kamel
- 2 Department of Neurology, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Jared Knopman
- 1 Department of Neurosurgery, Weill Cornell Medical Center, New York Presbyterian Hospital, New York, NY, USA
| |
Collapse
|
226
|
You W, Zhu Y, Wang Y, Liu W, Wang H, Wen L, Yang X. Prevalence of and risk factors for recurrence of chronic subdural hematoma. Acta Neurochir (Wien) 2018. [PMID: 29532258 DOI: 10.1007/s00701-018-3513-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Chronic subdural hematoma (CSDH) is a common disease in neurosurgical practice with substantial recurrence rate. We aimed to estimate recurrence rate of CSDH and to identify risk factors for CSDH recurrence. METHODS We retrospectively studied consecutive cases with CSDH and performed surgical therapy in our hospital. Univariate and multivariate logistic regression analyses were performed to identify factors associated with recurrence of CSDH. RESULTS A total of 226 patients with CSDH were included; 34 patients recurred after surgery with a recurrence rate of 15.0%. Univariate analysis showed that the recurrence group had more patients with homogenous hyper-dense hematoma (20.6 vs 6.3%, p = 0.035) and shorter duration of subdural drainage post-surgery (1.2 ± 1.4 vs 1.5 ± 0.9, p = 0.022) than the non-recurrence group. Logistic regression analysis revealed that duration of subdural drainage (OR = 0.66, p = 0.05) and hyper-dense of hematoma (OR = 4.94, p = 0.012) were independent predictors for CSDH recurrence. CONCLUSIONS Homogenous hyper-dense of hematoma and duration of subdural drainage post-surgery were independent predictors for CSDH recurrence; longer duration of postoperative subdural drainage was associated with lower risk of recurrence.
Collapse
Affiliation(s)
- Wendong You
- Department of Neurosurgery, First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, Zhejiang Province, 310003, China
| | - Yuanrun Zhu
- Department of Neurosurgery, First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, Zhejiang Province, 310003, China
| | - Yadong Wang
- Department of Neurosurgery, First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, Zhejiang Province, 310003, China
| | - Wenchao Liu
- Department of Neurosurgery, First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, Zhejiang Province, 310003, China
| | - Hao Wang
- Department of Neurosurgery, First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, Zhejiang Province, 310003, China
| | - Liang Wen
- Department of Neurosurgery, First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, Zhejiang Province, 310003, China
| | - Xiaofeng Yang
- Department of Neurosurgery, First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, Zhejiang Province, 310003, China.
| |
Collapse
|
227
|
Wang G, Yu J. Remote acute subarachnoid hemorrhage after drainage of chronic subdural hematoma: A case report and review of the literature. Int J Surg Case Rep 2018. [PMID: 29529540 PMCID: PMC5928297 DOI: 10.1016/j.ijscr.2018.02.044] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Chronic subdural hematoma (CSDH) can be treated by a relatively simple burr hole surgery. Acute subarachnoid hemorrhage (SAH) occurring after surgery for CSDH has been reported as a rare but severe complication. So, we reported this case. Acute SAH occurring after surgery for CSDH is a rare but severe complication associated with the postoperative drainage speed. Rapid variation of cerebral blood flow and perioperative parenchymal shift occur due to the speed of the drainage system. Thus, the height of the tube should not be too low, thereby avoiding“too rapid or too excessive postoperative drainage.” Slow decompression with closed-system drainage is recommended to avoid rapid dynamic intracranial changes during drainage of a subdural hematoma, including brain shift or restoration of normal perfusion, to prevent devastating complications.
Introduction Chronic subdural hematoma(CSDH) can be treated by a relatively simple burr hole surgery. Acute subarachnoid hemorrhage (SAH) occurring after surgery for CSDH has been reported as a rare but severe complication. Case report An 88-year-old female complained of progressive headache and dizziness for one month. A right fronto-temporo-parietal CSDH with a shift in the midline structures and lateral ventricle compression was shown by computed tomography (CT) scans. Closed-system drainage of the hematoma was performed via one burr hole under general anesthesia. Two hours after we began draining the hematoma at the patient’s bedside, the patient complained of headache and exhibited impaired consciousness that progressively degenerated. The drainage bag collected 200 ml of bloody liquid overa short time. A subsequent CT scan revealed SAH and an acute subdural hematoma. A CT angiogram excluded the presence of intracranial aneurysms. The patient died of hypostatic pneumonia after 15 days despite conservative medical management. Discussion Relevant literature was reviewed, and we believe that the occurrence of a hematoma in the opposite hemisphere and the hyperperfusion resulted from the rapid drainage of the hematoma, which caused the rupture of weak bridging veins during drainage. Conclusion Slow decompression with closed-system drainage is recommended to avoid rapid dynamic intracranial changes during drainage of a subdural hematoma, including brain shift or restoration of normal perfusion,to prevent devastating complications.
Collapse
Affiliation(s)
- Guangming Wang
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin, 130021, PR China.
| | - Jinlu Yu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin, 130021, PR China.
| |
Collapse
|
228
|
Evidence based diagnosis and management of chronic subdural hematoma: A review of the literature. J Clin Neurosci 2018; 50:7-15. [PMID: 29428263 DOI: 10.1016/j.jocn.2018.01.050] [Citation(s) in RCA: 105] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Accepted: 01/08/2018] [Indexed: 11/23/2022]
Abstract
Chronic subdural hematomas are encapsulated blood collections within the dural border cells with characteristic outer "neomembranes". Affected patients are more often male and typically above the age of 70. Imaging shows crescentic layering of fluid in the subdural space on a non-contrast computed tomography (CT) scan, best appreciated on sagittal or coronal reformats. Initial medical management involves reversing anticoagulant/antiplatelet therapies, and often initiation of anti-epileptic drugs (AEDs). Operative interventions, such as twist-drill craniostomy (TDC), burr-hole craniostomy (BHC), and craniotomy are indicated if imaging implies compression (maximum fluid collection thickness >1 cm) or the patient is symptomatic. The effectiveness of various surgical techniques remains poorly characterized, with sparse level 1 evidence, variable outcome measures, and various surgical techniques. Postoperatively, subdural drains can decrease recurrence and sequential compression devices can decrease embolic complications, while measures such as early mobilization and re-initiation of anticoagulation need further study. Non-operative management, including steroid therapy, etizolam, tranexamic acid, and angiotensin converting enzyme inhibitors (ACEI) also remain poorly studied. Recurrent hemorrhages are a major complication affecting around 10-20% of patients, and therefore close follow-up is essential.
Collapse
|
229
|
Hoffman H, Ziechmann R, Beutler T, Verhave B, Chin LS. First-line management of chronic subdural hematoma with the subdural evacuating port system: Institutional experience and predictors of outcomes. J Clin Neurosci 2018; 50:221-225. [PMID: 29428265 DOI: 10.1016/j.jocn.2018.01.068] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Revised: 12/04/2017] [Accepted: 01/18/2018] [Indexed: 11/28/2022]
Abstract
Chronic subdural hematoma (cSDH) is a common condition that disproportionately affects older patients. Given the greater risks of general anesthesia in this population, interest has turned towards less invasive surgical approaches such as the subdural evacuating port system (SEPS; Medtronic, Inc., Minneapolis, MN). There is a relative dearth of information about the outcomes following this procedure. Here, we present our institution's experience with SEPS and analyze factors associated with the outcomes. Using a prospectively maintained institutional database, we retrospectively identified all patients who presented with cSDH and received first line therapy with SEPS. Pre- and post-operative clinical and radiographic data was obtained from the electronic health record. Outcomes included success or failure, Modified Rankin Scale (mRS) at discharge, length of stay (LOS), and discharge disposition. A total of 126 patients met the inclusion criteria (36 females and 90 males; mean age of 71.6 years). None of the pre-procedural clinical or radiographic variables were associated with the likelihood of a successful outcome. Increasing age was associated with non-routine hospital discharge (p = 0.003), and lower presenting GCS was associated with longer hospital stay (p = 0.005). Greater thickness of the cSDH was associated with a lower likelihood of having a favorable outcome (mRS ≥ 3; p = 0.003). SEPS is an effective first-line therapy for cSDH. Variables previously reported to limit the effectiveness of the technique (presence of septations, mixed density collections) were not associated with treatment failure.
Collapse
Affiliation(s)
- Haydn Hoffman
- Department of Neurosurgery, State University of New York Upstate, 750 E. Adams St., Syracuse, NY 13202, United States.
| | - Robert Ziechmann
- Department of Neurosurgery, State University of New York Upstate, 750 E. Adams St., Syracuse, NY 13202, United States
| | - Timothy Beutler
- Department of Neurosurgery, State University of New York Upstate, 750 E. Adams St., Syracuse, NY 13202, United States
| | - Brendon Verhave
- Department of Neurosurgery, State University of New York Upstate, 750 E. Adams St., Syracuse, NY 13202, United States
| | - Lawrence S Chin
- Department of Neurosurgery, State University of New York Upstate, 750 E. Adams St., Syracuse, NY 13202, United States
| |
Collapse
|
230
|
Gokcal E, Pasi M, Fisher M, Gurol ME. Atrial Fibrillation for the Neurologist: Preventing both Ischemic and Hemorrhagic Strokes. Curr Neurol Neurosci Rep 2018; 18:6. [PMID: 29411147 PMCID: PMC5801393 DOI: 10.1007/s11910-018-0813-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW This review aims to help neurologists managing atrial fibrillation (AF) patients who had an ischemic stroke and/or with intracranial hemorrhage (ICH) markers, therefore at high embolic/hemorrhagic risks. RECENT FINDINGS Implantable loop recorders have substantially improved the accuracy of AF detection. Recent research yielded a set of powerful neuroimaging markers that can stratify ICH risk. Direct oral anticoagulants (DOAC) are easier to use with a lower ICH risk than warfarin in a general AF population. Finally, the FDA-approved left atrial appendage closure (LAAC) with the WATCHMAN device provides an option without the need for life-long anticoagulation. In this review, we introduce the concept of preventing both ischemic and hemorrhagic strokes in AF patients through accurate AF diagnosis and stratification of both embolic and ICH risks. LAAC can be considered in patients at higher hemorrhagic risks while warfarin/DOAC use should be individualized in the majority of AF patients at a low risk of bleeding.
Collapse
Affiliation(s)
- Elif Gokcal
- Department of Neurology, Bezmialem University, Istanbul, Turkey
| | - Marco Pasi
- Department of Neurology, Hemorrhagic Stroke Research Program, Massachusetts General Hospital, 175 Cambridge Street, Suite 300, Boston, MA, 02114, USA
| | - Marc Fisher
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - M Edip Gurol
- Department of Neurology, Hemorrhagic Stroke Research Program, Massachusetts General Hospital, 175 Cambridge Street, Suite 300, Boston, MA, 02114, USA.
| |
Collapse
|
231
|
Phan K, Abi-Hanna D, Kerferd J, Lu VM, Dmytriw AA, Ho YT, Fairhall J, Reddy R, Wilson P. Resumption of Antithrombotic Agents in Chronic Subdural Hematoma: A Systematic Review and Meta-analysis. World Neurosurg 2018; 109:e792-e799. [DOI: 10.1016/j.wneu.2017.10.091] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Revised: 10/15/2017] [Accepted: 10/17/2017] [Indexed: 01/28/2023]
|
232
|
Toi H, Kinoshita K, Hirai S, Takai H, Hara K, Matsushita N, Matsubara S, Otani M, Muramatsu K, Matsuda S, Fushimi K, Uno M. Present epidemiology of chronic subdural hematoma in Japan: analysis of 63,358 cases recorded in a national administrative database. J Neurosurg 2018; 128:222-228. [DOI: 10.3171/2016.9.jns16623] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEAging of the population may lead to epidemiological changes with respect to chronic subdural hematoma (CSDH). The objectives of this study were to elucidate the current epidemiology and changing trends of CSDH in Japan. The authors analyzed patient information based on reports using a Japanese administrative database associated with the diagnosis procedure combination (DPC) system.METHODSThis study included patients with newly diagnosed CSDH who were treated in hospitals participating in the DPC system. The authors collected data from the administrative database on the following clinical and demographic characteristics: patient age, sex, and level of consciousness on admission; treatment procedure; and outcome at discharge.RESULTSA total of 63,358 patients with newly diagnosed CSDH and treated in 1750 DPC participation hospitals were included in this study. Analysis according to patient age showed that the most common age range for these patients was the 9th decade of life (in their 80s). More than half of patients 70 years old or older presented with some kind of disturbance of consciousness. Functional outcomes at discharge were good in 71.6% (modified Rankin Scale [mRS] score 0–2) of cases and poor in 28.4% (mRS score 3–6). The percentage of poor outcomes tended to be higher in elderly patients. Approximately 40% of patients 90 years old or older could not be discharged to home. The overall recurrence rate for CSDH was 13.1%.CONCLUSIONSThis study shows a chronological change in the age distribution of CSDH among Japanese patients, which may be affecting the prognosis of this condition. In the aging population of contemporary Japan, patients in their 80s were affected more often than patients in other age categories, and approximately 30% of patients with CSDH required some help at discharge. CSDH thus may no longer have as good a prognosis as had been thought.
Collapse
Affiliation(s)
- Hiroyuki Toi
- 1Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Okayama
| | - Keita Kinoshita
- 1Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Okayama
| | - Satoshi Hirai
- 1Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Okayama
| | - Hiroki Takai
- 1Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Okayama
| | - Keijiro Hara
- 1Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Okayama
| | | | - Shunji Matsubara
- 1Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Okayama
| | - Makoto Otani
- 2Department of Preventive Medicine and Community Health, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Fukuoka; and
| | - Keiji Muramatsu
- 2Department of Preventive Medicine and Community Health, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Fukuoka; and
| | - Shinya Matsuda
- 2Department of Preventive Medicine and Community Health, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Fukuoka; and
| | - Kiyohide Fushimi
- 3Department of Health Policy and Informatics, Tokyo Medical and Dental University, Tokyo, Japan
| | - Masaaki Uno
- 1Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Okayama
| |
Collapse
|
233
|
Abstract
Surgery is the standard treatment for chronic subdural hematoma (CSDH), one of the common problems in neurosurgical practice. Although medical treatment was used by some authors and found some positive results, it is not accepted by many authors. The aim of this review is to give overall view of the medical management of CSDH. Action of various drugs in the pathophysiological cascade of formation of CSDH was depicted. The review of literature is done under three headings – the primary medical treatment of CSDH, adjuvant medical treatment with surgery, and the treatment of the recurrence. Various classifications of CSDH and the factors influencing the outcome of medical treatment are discussed. There is a role of medical treatment in a selected group of patients with CSDH. Well-designed, multicenter, randomized controlled trials are required to define the indications and standard protocols for the medical treatment of CSDH.
Collapse
Affiliation(s)
- Amit Kumar Thotakura
- Department of Neurosurgery, NRI Academy of Sciences, Guntur, Andhra Pradesh, India
| | | |
Collapse
|
234
|
Gurol ME. Nonpharmacological Management of Atrial Fibrillation in Patients at High Intracranial Hemorrhage Risk. Stroke 2018; 49:247-254. [PMID: 29203684 PMCID: PMC5847291 DOI: 10.1161/strokeaha.117.017081] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 10/24/2017] [Accepted: 11/01/2017] [Indexed: 12/17/2022]
Affiliation(s)
- M Edip Gurol
- From the Department of Neurology, Massachusetts General Hospital, Boston.
| |
Collapse
|
235
|
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.
Collapse
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.
| |
Collapse
|
236
|
Pripp AH, Stanišić M. Association between biomarkers and clinical characteristics in chronic subdural hematoma patients assessed with lasso regression. PLoS One 2017; 12:e0186838. [PMID: 29107999 PMCID: PMC5673201 DOI: 10.1371/journal.pone.0186838] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Accepted: 10/09/2017] [Indexed: 11/18/2022] Open
Abstract
Chronic subdural hematoma (CSDH) is characterized by an “old” encapsulated collection of blood and blood breakdown products between the brain and its outermost covering (the dura). Recognized risk factors for development of CSDH are head injury, old age and using anticoagulation medication, but its underlying pathophysiological processes are still unclear. It is assumed that a complex local process of interrelated mechanisms including inflammation, neomembrane formation, angiogenesis and fibrinolysis could be related to its development and propagation. However, the association between the biomarkers of inflammation and angiogenesis, and the clinical and radiological characteristics of CSDH patients, need further investigation. The high number of biomarkers compared to the number of observations, the correlation between biomarkers, missing data and skewed distributions may limit the usefulness of classical statistical methods. We therefore explored lasso regression to assess the association between 30 biomarkers of inflammation and angiogenesis at the site of lesions, and selected clinical and radiological characteristics in a cohort of 93 patients. Lasso regression performs both variable selection and regularization to improve the predictive accuracy and interpretability of the statistical model. The results from the lasso regression showed analysis exhibited lack of robust statistical association between the biomarkers in hematoma fluid with age, gender, brain infarct, neurological deficiencies and volume of hematoma. However, there were associations between several of the biomarkers with postoperative recurrence requiring reoperation. The statistical analysis with lasso regression supported previous findings that the immunological characteristics of CSDH are local. The relationship between biomarkers, the radiological appearance of lesions and recurrence requiring reoperation have been inclusive using classical statistical methods on these data, but lasso regression revealed an association with inflammatory and angiogenic biomarkers in hematoma fluid. We thus suggest that lasso regression should be a recommended statistical method in research on biological processes in CSDH patients.
Collapse
Affiliation(s)
- Are Hugo Pripp
- Oslo Centre of Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, Oslo, Norway
- * E-mail:
| | - Milo Stanišić
- Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
| |
Collapse
|
237
|
Alliez JR. Ematoma subdurale cronico dell’adulto. Neurologia 2017. [DOI: 10.1016/s1634-7072(17)86805-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
|
238
|
Yao Z, Hu X, Ma L, You C. Dexamethasone for chronic subdural haematoma: a systematic review and meta-analysis. Acta Neurochir (Wien) 2017; 159:2037-2044. [PMID: 28865006 DOI: 10.1007/s00701-017-3309-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 08/17/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND Chronic subdural haematoma is a common but retractable neurological disease in the elderly with a high rate of recurrence. Dexamethasone (DX) either as monotherapy or adjuvant therapy has been applied clinically, but its effectiveness and feasibility remain controversial. We conducted this review to clarify this issue. METHODS With a systematic review through multiple databases, we retrieved eligible English language publications and extracted relevant data to perform meta-analyses. The respective risk ratio (RR) and its 95% confidence interval (CI) were pooled to evaluate the overall effect. RESULTS Our meta-analysis showed overall that DX (alone or adjuvant) resulted in a lower recurrence rate when compared with non-DX therapy (RR, 0.54; 95% CI, 0.33-0.88; p = 0.01), but sensitivity analysis by excluding the most influential study achieved inconsistent results. The pooled effect revealed no statistical difference on recurrence rate between DX alone and non-DX therapy or surgical therapy (RR, 0.86; 95% CI, 0.43-1.71; p = 0.66) (RR, 0.89; 95% CI, 0.43-1.85; p = 0.76). Comparison between DX alone with the surgical therapy demonstrated no difference on the poor outcome (RR, 0.40; 95% CI, 0.15-1.04; p = 0.06). CONCLUSIONS We had no enough evidence to support DX use as an effective alternation to surgical therapy. But adjuvant DX use may facilitate the surgical therapy by reducing recurrence. Further study focusing on adjuvant DX was required.
Collapse
Affiliation(s)
- Zhong Yao
- Department of Neurosurgery, West China Hospital, Sichuan University and West China Brain Research Centre, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, China
| | - Xin Hu
- Department of Neurosurgery, West China Hospital, Sichuan University and West China Brain Research Centre, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, China
| | - Lu Ma
- Department of Neurosurgery, West China Hospital, Sichuan University and West China Brain Research Centre, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, China
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University and West China Brain Research Centre, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, China.
| |
Collapse
|
239
|
Weimer JM, Gordon E, Frontera JA. Predictors of Functional Outcome After Subdural Hematoma: A Prospective Study. Neurocrit Care 2017; 26:70-79. [PMID: 27230968 DOI: 10.1007/s12028-016-0279-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although the incidence of subdural hematoma (SDH) has increased in the US in the last decade, limited prospective data exist examining risk factors for poor outcome. METHODS A prospective, observational study of consecutive SDH patients was conducted from 7/2008 to 11/2011. Baseline clinical data, hospital and surgical course, complications, and imaging data were compared between those with good versus poor 3-month outcomes (modified Rankin Scores [mRS] 0-3 vs. 4-6). A multivariable logistic regression model was constructed to identify independent predictors of poor outcome. RESULTS 116 SDH patients (18 acute, 56 mixed acute/subacute/chronic, 42 subacute/chronic) were included. At 3 months, 61 (53 %) patients had good outcomes (mRS 0-3) while 55 (47 %) were severely disabled or dead (mRS 4-6). Of those who underwent surgical evacuation, 54/94 (57 %) had good outcomes compared to 7/22 (32 %) who did not (p = 0.030). Patients with mixed acuity or subacute/chronic SDH had significantly better 3-month mRS with surgery (median mRS 1 versus 5 without surgery, p = 0.002) compared to those with only acute SDH (p = 0.494). In multivariable analysis, premorbid mRS, age, admission Glasgow Coma Score, history of smoking, and fever were independent predictors of poor 3-month outcome (all p < 0.05; area under the curve 0.90), while SDH evacuation tended to improve outcomes (adjusted OR 3.90, 95 % CI 0.96-18.9, p = 0.057). CONCLUSIONS Nearly 50 % of SDH patients were dead or moderate-severely disabled at 3 months. Older age, poor baseline, poor admission neurological status, history of smoking, and fever during hospitalization predicted poor outcomes, while surgical evacuation was associated with improved outcomes among those with mixed acuity or chronic/subacute SDH.
Collapse
Affiliation(s)
- Jonathan M Weimer
- Cerebrovascular Center of the Neurological Institute, Cleveland Clinic, 9500 Euclid Ave. S80, Cleveland, OH, 44195, USA
| | - Errol Gordon
- Neuroscience Intensive Care Unit, Department of Critical Care, Mount Sinai School of Medicine, New York, NY, USA
| | - Jennifer A Frontera
- Cerebrovascular Center of the Neurological Institute, Cleveland Clinic, 9500 Euclid Ave. S80, Cleveland, OH, 44195, USA.
| |
Collapse
|
240
|
Soleman J, Kamenova M, Lutz K, Guzman R, Fandino J, Mariani L. Drain Insertion in Chronic Subdural Hematoma: An International Survey of Practice. World Neurosurg 2017; 104:528-536. [DOI: 10.1016/j.wneu.2017.04.134] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 04/18/2017] [Accepted: 04/20/2017] [Indexed: 10/19/2022]
|
241
|
Hussain R, Afzal M, Joshi S, Dardis R, Siddique S, Beltechi R, Amit A, El-Maghraby H, Saxena A, Shad A. Factors affecting the survival following surgical treatment of chronic subdural haematoma: Single institutional experience. J Clin Neurosci 2017; 44:75-79. [PMID: 28687445 DOI: 10.1016/j.jocn.2017.06.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 06/18/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Chronic subdural haematoma (CSDH) is one of the most commonly treated condition in neurosurgery. It affects elderly populations who often have significant medical co-morbidities resulting in poor prognosis. The study aimed at identifying clinical factors influencing the survival following surgical management of CSDH. METHODS Retrospective study included 267 cases that underwent surgery for CSDH and followed over 5-year period (2010-2015); data retrieved with reference to operation details, radiology reports and discharge. Using logistic and Cox regression analysis, the patient survival data was analysed with respect to patient demographics, type of surgery, co-morbidities, anticoagulation treatment, and discharge destination. RESULTS The overall survival in the cohort was 37.0months (IQR: 20.0-60.0). The median age of the patients was 76years (IQR: 66-82) and the median length of hospital stay was 10days (range 1-126days; IQR: 6-17days). The recurrence rate was 6.37% (n=17). Fifty-three (19.85%) patients recorded deceased on the IPM database as of October 2016 and of those 11 died in hospital. Univariate Cox-regression analysis revealed increased age (HR: 1.80; 95%CI: 1.04-3.11), length of hospital stay (HR: 2.50; 95%CI: 1.41-4.41) and number of co-morbidities (HR: 2.19; 95%CI: 1.26-3.79) were associated with poor prognosis. Glasgow coma scale (GCS) at discharge was found to be significantly associated with survival whilst anticoagulation treatment did not. Multivariate analysis confirmed similar findings significant statistically. CONCLUSION Age at admission, median length of hospital stay, number of co-morbidities, GCS at discharge and discharge destination have been found to influence survival significant statistically.
Collapse
Affiliation(s)
- Rahim Hussain
- Department of Neurosurgery, University Hospital Coventry and Warwickshire, Coventry CV2 2DX, UK.
| | - Mohammed Afzal
- Department of Neurosurgery, University Hospital Coventry and Warwickshire, Coventry CV2 2DX, UK
| | - Shabin Joshi
- Department of Neurosurgery, University Hospital Coventry and Warwickshire, Coventry CV2 2DX, UK
| | - Ronan Dardis
- Department of Neurosurgery, University Hospital Coventry and Warwickshire, Coventry CV2 2DX, UK
| | - Shahid Siddique
- Department of Neurosurgery, University Hospital Coventry and Warwickshire, Coventry CV2 2DX, UK
| | - Radu Beltechi
- Department of Neurosurgery, University Hospital Coventry and Warwickshire, Coventry CV2 2DX, UK
| | - Amit Amit
- Department of Neurosurgery, University Hospital Coventry and Warwickshire, Coventry CV2 2DX, UK
| | - Hussein El-Maghraby
- Department of Neurosurgery, University Hospital Coventry and Warwickshire, Coventry CV2 2DX, UK
| | - Amar Saxena
- Department of Neurosurgery, University Hospital Coventry and Warwickshire, Coventry CV2 2DX, UK
| | - Amjad Shad
- Department of Neurosurgery, University Hospital Coventry and Warwickshire, Coventry CV2 2DX, UK
| |
Collapse
|
242
|
Uno M, Toi H, Hirai S. Chronic Subdural Hematoma in Elderly Patients: Is This Disease Benign? Neurol Med Chir (Tokyo) 2017; 57:402-409. [PMID: 28652561 PMCID: PMC5566699 DOI: 10.2176/nmc.ra.2016-0337] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
As the world population becomes progressively older, the overall incidence of chronic subdural hematoma (CSDH) is increasing. Peak age of onset for CSDH has also increased, and recently the 80-year-old level has a peak. Many patients with CSDH have had prior treatment with anticoagulants and antiplatelet drugs, which have an accompanying risk of CSDH. In elderly patients with CSDH, symptoms of cognitive change (memory disturbance, urinary incontinence, and decreased activity) and disturbance of consciousness at admission were more frequent compared to younger patients with CSDH. The literature actually offers conflicting advice regarding CSDH treatment; however, burr hole surgery with drainage under local anesthesia is the most common surgical procedure, even in elderly patients. The recurrence rate of CSDH has not decreased over recent decades, and it has ranged from 0.36-33.3%. Outcomes in patients over 75 years old was significantly worse than for those younger than 75. Moreover, long-term outcomes for elderly patients with CSDH are poor. CSDH in the elderly is no longer a benign disease. In the future, it will be important for us to understand the mechanisms of onset and recurrence of CSDH and to develop more effective medical treatments and noninvasive surgical techniques for elderly patients.
Collapse
Affiliation(s)
- Masaaki Uno
- Department of Neurosurgery, Kawasaki Medical School
| | - Hiroyuki Toi
- Department of Neurosurgery, Kawasaki Medical School
| | | |
Collapse
|
243
|
Sjåvik K, Bartek J, Sagberg LM, Henriksen ML, Gulati S, Ståhl FL, Kristiansson H, Solheim O, Förander P, Jakola AS. Assessment of drainage techniques for evacuation of chronic subdural hematoma: a consecutive population-based comparative cohort study. J Neurosurg 2017; 133:1113-1119. [PMID: 28644099 DOI: 10.3171/2016.12.jns161713] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 12/21/2016] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Surgery for chronic subdural hematoma (CSDH) is one of the most common neurosurgical procedures. The benefit of postoperative passive subdural drainage compared with no drains has been established, but other drainage techniques are common, and their effectiveness compared with passive subdural drains remains unknown. METHODS In Scandinavian population-based cohorts the authors conducted a consecutive, parallel cohort study to compare different drainage techniques. The techniques used were continuous irrigation and drainage (CID cohort, n = 166), passive subdural drainage (PD cohort, n = 330), and active subgaleal drainage (AD cohort, n = 764). The primary end point was recurrence in need of reoperation within 6 months of index surgery. Secondary end points were complications, perioperative mortality, and overall survival. The analyses were based on direct regional comparison (i.e., surgical strategy). RESULTS Recurrence in need of surgery was observed in 18 patients (10.8%) in the CID cohort, in 66 patients (20.0%) in the PD cohort, and in 85 patients (11.1%) in the AD cohort (p < 0.001). Complications were more common in the CID cohort (14.5%) compared with the PD (7.3%) and AD (8.1%) cohorts (p = 0.019). Perioperative mortality rates were similar between cohorts (p = 0.621). There were some differences in baseline and treatment characteristics possibly interfering with the above-mentioned results. However, after adjusting for differences in baseline and treatment characteristics in a regression model, the drainage techniques were still significantly associated with clinical outcome (p < 0.001 for recurrence, p = 0.017 for complications). CONCLUSIONS Compared with the AD cohort, more recurrences were observed in the PD cohort and more complications in the CID cohort, also after adjustment for differences at baseline. Although the authors cannot exclude unmeasured confounding factors when comparing centers, AD appears superior to the more common PD.Clinical trial registration no.: NCT01930617 (clinicaltrials.gov).
Collapse
Affiliation(s)
- Kristin Sjåvik
- 2Department of Neurosurgery, University Hospital of North Norway, Tromsø, Norway
| | - Jiri Bartek
- 1Department of Clinical Neuroscience, Karolinska Institutet, and Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
- 7Department of Neurosurgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Lisa Millgård Sagberg
- 3Department of Neuroscience, Norwegian University of Science and Technology, Trondheim, Norway
- 4Department of Neurosurgery, St. Olavs University Hospital, Trondheim, Norway
| | | | - Sasha Gulati
- 3Department of Neuroscience, Norwegian University of Science and Technology, Trondheim, Norway
- 4Department of Neurosurgery, St. Olavs University Hospital, Trondheim, Norway
| | - Fredrik L Ståhl
- 1Department of Clinical Neuroscience, Karolinska Institutet, and Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Helena Kristiansson
- 1Department of Clinical Neuroscience, Karolinska Institutet, and Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Ole Solheim
- 3Department of Neuroscience, Norwegian University of Science and Technology, Trondheim, Norway
- 4Department of Neurosurgery, St. Olavs University Hospital, Trondheim, Norway
| | - Petter Förander
- 1Department of Clinical Neuroscience, Karolinska Institutet, and Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Asgeir Store Jakola
- 4Department of Neurosurgery, St. Olavs University Hospital, Trondheim, Norway
- 6Institute of Neuroscience and Physiology, University of Gothenburg, Sahlgrenska Academy, Gothenburg, Sweden; and
| |
Collapse
|
244
|
Henaux PL, Le Reste PJ, Laviolle B, Morandi X. Steroids in chronic subdural hematomas (SUCRE trial): study protocol for a randomized controlled trial. Trials 2017; 18:252. [PMID: 28583162 PMCID: PMC5460366 DOI: 10.1186/s13063-017-1990-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 05/16/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chronic subdural hematoma (CSDH) is a common neurological pathology, especially in older patients. The actual "gold standard" of treatment is surgical evacuation, with various techniques used across neurosurgical teams. Over the years, there has been growing evidence that inflammatory processes play a major role in the pathogenesis of CSDH. In that context, the use of corticosteroids has been proposed alone or as an adjuvant treatment to surgery. However, this practice remains very empirical and there is a need for high-quality-of-evidence studies to clarify the role of corticosteroids in the management of CSDH. METHODS/DESIGN We propose a double-blind, randomized controlled trial comparing methylprednisolone versus placebo in the treatment of CSDH without clinical and/or radiological signs of severity. The treatment will be administered daily for a duration of 3 weeks, at a dose of 1 mg/kg. The primary endpoint will be the delay of occurrence of surgical treatment at 1 month following the introduction of the treatment. Secondary endpoints will include the rate of recourse to surgery, survival rate, quality of life and functional assessments, occurrence of systemic secondary effects and radiological assessment of the response to treatment. This multimodal assessment will be done at 1, 3 and 6 months. Two hundred and two patients (101 per arm) are expected to be included considering our primary hypotheses. DISCUSSION This trial started in June 2016; its results may open interesting alternatives to surgery in the management of patients harboring a CSDH, and may provide insights into the natural history of this common pathology. TRIAL REGISTRATION ClinicalTrials.gov, ID: NCT02650609 . Registered on 4 January 2016. Graphical output of the OBF boundaries.
Collapse
Affiliation(s)
- Pierre-Louis Henaux
- Department of Neurosurgery, Rennes University Hospital, 2, rue Henri Le Guilloux, 35033, Rennes, Cedex 9, France. .,Rennes 1 University, Faculty of Medicine, 2 Avenue du Professeur Léon Bernard, 35043, Rennes, Cedex 4, France.
| | - Pierre-Jean Le Reste
- Department of Neurosurgery, Rennes University Hospital, 2, rue Henri Le Guilloux, 35033, Rennes, Cedex 9, France.,Rennes 1 University, Faculty of Medicine, 2 Avenue du Professeur Léon Bernard, 35043, Rennes, Cedex 4, France
| | - Bruno Laviolle
- Department of Clinical Pharmacology, Rennes University Hospital, 2, rue Henri Le Guilloux, 35033, Rennes, Cedex 9, France.,Inserm, CIC 1414 Clinical Investigation Centre, Rennes University Hospital, 2, rue Henri Le Guilloux, 35033, Rennes, Cedex 9, France.,Rennes 1 University, Faculty of Medicine, 2 Avenue du Professeur Léon Bernard, 35043, Rennes, Cedex 4, France
| | - Xavier Morandi
- Department of Neurosurgery, Rennes University Hospital, 2, rue Henri Le Guilloux, 35033, Rennes, Cedex 9, France.,Rennes 1 University, Faculty of Medicine, 2 Avenue du Professeur Léon Bernard, 35043, Rennes, Cedex 4, France
| |
Collapse
|
245
|
Correlation of vascular endothelial growth factor with magnetic resonance imaging in chronic subdural hematomas. J Neurol Sci 2017; 377:149-154. [DOI: 10.1016/j.jns.2017.04.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 03/31/2017] [Accepted: 04/10/2017] [Indexed: 02/02/2023]
|
246
|
Edlmann E, Giorgi-Coll S, Whitfield PC, Carpenter KLH, Hutchinson PJ. Pathophysiology of chronic subdural haematoma: inflammation, angiogenesis and implications for pharmacotherapy. J Neuroinflammation 2017; 14:108. [PMID: 28558815 PMCID: PMC5450087 DOI: 10.1186/s12974-017-0881-y] [Citation(s) in RCA: 325] [Impact Index Per Article: 46.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 05/15/2017] [Indexed: 02/08/2023] Open
Abstract
Chronic subdural haematoma (CSDH) is an encapsulated collection of blood and fluid on the surface of the brain. Historically considered a result of head trauma, recent evidence suggests there are more complex processes involved. Trauma may be absent or very minor and does not explain the progressive, chronic course of the condition. This review focuses on several key processes involved in CSDH development: angiogenesis, fibrinolysis and inflammation. The characteristic membrane surrounding the CSDH has been identified as a source of fluid exudation and haemorrhage. Angiogenic stimuli lead to the creation of fragile blood vessels within membrane walls, whilst fibrinolytic processes prevent clot formation resulting in continued haemorrhage. An abundance of inflammatory cells and markers have been identified within the membranes and subdural fluid and are likely to contribute to propagating an inflammatory response which stimulates ongoing membrane growth and fluid accumulation. Currently, the mainstay of treatment for CSDH is surgical drainage, which has associated risks of recurrence requiring repeat surgery. Understanding of the underlying pathophysiological processes has been applied to developing potential drug treatments. Ongoing research is needed to identify if these therapies are successful in controlling the inflammatory and angiogenic disease processes leading to control and resolution of CSDH.
Collapse
Affiliation(s)
- Ellie Edlmann
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Box 167, Cambridge Biomedical Campus, Cambridge, CB2 0QQ UK
| | - Susan Giorgi-Coll
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Box 167, Cambridge Biomedical Campus, Cambridge, CB2 0QQ UK
| | - Peter C. Whitfield
- Southwest Neurosurgical Centre, Plymouth Hospitals NHS Trust, Plymouth, PL6 8DH UK
| | - Keri L. H. Carpenter
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Box 167, Cambridge Biomedical Campus, Cambridge, CB2 0QQ UK
| | - Peter J. Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Box 167, Cambridge Biomedical Campus, Cambridge, CB2 0QQ UK
| |
Collapse
|
247
|
Sahyouni R, Mahboubi H, Tran P, Roufail JS, Chen JW. Membranectomy in Chronic Subdural Hematoma: Meta-Analysis. World Neurosurg 2017; 104:418-429. [PMID: 28512051 DOI: 10.1016/j.wneu.2017.05.030] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 05/02/2017] [Accepted: 05/04/2017] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Initial management strategies of chronic subdural hematoma (cSDH) are controversial and range from bedside twist-drill or burr-hole drainage to craniotomy with membranectomy (CWM). We aim to 1) perform a meta-analysis of the available data on the outcomes of CWM for treatment of cSDH in published English-language literature and 2) evaluate collective outcomes of CWM with respect to morbidity, mortality, and recurrence rates. METHODS A search of English-language literature performed in PubMed, Ovid, and Cochrane databases using key words ("subdural hematoma" or "chronic subdural hematoma") and ("membrane" or "membranectomy") from inception to December 2016 was conducted. Studies reporting outcomes of CWM in cSDH were included. Mortality, morbidity, follow-up duration, and recurrence rate data were extracted and analyzed. Pooled estimates and confidence intervals (CIs) were calculated for all outcomes using a random-effects model. RESULTS Of 301 articles found, 17 articles containing 5369 patients met our eligibility criteria. Mean follow-up duration ranged from 1-30.8 months. Collective mean mortality and morbidity rates were 3.7% and 6.9%, respectively (95% CI 2-5.4% and 2.1-11.6%; P < 0.001 and P = 0.004). The collective mean recurrence rate was 7.6% (95% CI: 5%-10.2%; P < 0.001). CONCLUSIONS Clinical data on outcomes of CWM in cSDH are limited to single institutional analyses, with considerable variation in recurrence rates and follow-up time. The rates we reported are comparable with the 5% mortality and 3%-12% morbidity rates and lower than the 10%-21% recurrence rate in the literature for burr holes or craniotomy without membranectomy. This meta-analysis provides an in-depth analysis of available data and reviews reported outcomes.
Collapse
Affiliation(s)
- Ronald Sahyouni
- School of Medicine MSTP, University of California, Irvine, California, USA; Department of Biomedical Engineering, University of California, Irvine, California, USA
| | - Hossein Mahboubi
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California, USA
| | - Peter Tran
- Department of Neurological Surgery, University of California, Irvine, California, USA
| | - John S Roufail
- Department of Neurological Surgery, University of California, Irvine, California, USA
| | - Jefferson W Chen
- Department of Neurological Surgery, University of California, Irvine, California, USA.
| |
Collapse
|
248
|
|
249
|
|
250
|
|