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Korhonen TK, Arponen O, Steinruecke M, Pecorella I, Mee H, Yordanov S, Viaroli E, Guilfoyle MR, Kolias A, Timofeev I, Hutchinson P, Helmy A. Reduced temporal muscle thickness predicts shorter survival in patients undergoing chronic subdural haematoma drainage. J Cachexia Sarcopenia Muscle 2024; 15:1441-1450. [PMID: 38720242 PMCID: PMC11294050 DOI: 10.1002/jcsm.13489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 03/15/2024] [Accepted: 03/26/2024] [Indexed: 08/03/2024] Open
Abstract
BACKGROUND Chronic subdural haematoma (CSDH) drainage is a common neurosurgical procedure. CSDHs cause excess mortality, which is exacerbated by frailty. Sarcopenia contributes to frailty - its key component, low muscle mass, can be assessed using cross-sectional imaging. We aimed to examine the prognostic role of temporal muscle thickness (TMT) measured from preoperative computed tomography head scans among patients undergoing surgical CSDH drainage. METHODS We retrospectively identified all patients who underwent CSDH drainage within 1 year of February 2019. We measured their mean TMT from preoperative computed tomography scans, tested the reliability of these measurements, and evaluated their prognostic value for postoperative survival. RESULTS One hundred and eighty-eight (122, 65% males) patients (median age 78 years, IQR 70-85 years) were included. Thirty-four (18%) patients died within 2 years, and 51 (27%) died at a median follow-up of 39 months (IQR 34-42 months). Intra- and inter-observer reliability of TMT measurements was good-to-excellent (ICC 0.85-0.97, P < 0.05). TMT decreased with age (Pearson's r = -0.38, P < 0.001). Females had lower TMT than males (P < 0.001). The optimal TMT cut-off values for predicting two-year survival were 4.475 mm for males and 3.125 mm for females. TMT below these cut-offs was associated with shorter survival in both univariate (HR 3.24, 95% CI 1.85-5.67) and multivariate (HR 1.86, 95% CI 1.02-3.36) analyses adjusted for age, ASA grade and bleed size. The effect of TMT on mortality was not mediated by age. CONCLUSIONS In patients with CSDH, TMT measurements from preoperative imaging were reliable and contained prognostic information supplemental to previously known predictors of poor outcomes.
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Affiliation(s)
- Tommi K. Korhonen
- Division of Neurosurgery, Department of Clinical NeurosciencesCambridge University Hospitals NHS Foundation Trust & University of CambridgeCambridgeUK
- Department of Neurosurgery, Neurocenter OYSOulu University HospitalOuluFinland
- Department of Neurosurgery, Research Unit of Clinical NeurosciencesUniversity of OuluOuluFinland
| | - Otso Arponen
- Department of RadiologyUniversity of CambridgeCambridgeUK
- Faculty of Medicine and Health SciencesTampere UniversityTampereFinland
- Department of RadiologyTampere University HospitalTampereFinland
| | - Moritz Steinruecke
- Division of Neurosurgery, Department of Clinical NeurosciencesCambridge University Hospitals NHS Foundation Trust & University of CambridgeCambridgeUK
| | - Ilaria Pecorella
- Division of Neurosurgery, Department of Clinical NeurosciencesCambridge University Hospitals NHS Foundation Trust & University of CambridgeCambridgeUK
| | - Harry Mee
- Division of Neurosurgery, Department of Clinical NeurosciencesCambridge University Hospitals NHS Foundation Trust & University of CambridgeCambridgeUK
| | - Stefan Yordanov
- Division of Neurosurgery, Department of Clinical NeurosciencesCambridge University Hospitals NHS Foundation Trust & University of CambridgeCambridgeUK
| | - Edoardo Viaroli
- Division of Neurosurgery, Department of Clinical NeurosciencesCambridge University Hospitals NHS Foundation Trust & University of CambridgeCambridgeUK
| | - Mathew R. Guilfoyle
- Division of Neurosurgery, Department of Clinical NeurosciencesCambridge University Hospitals NHS Foundation Trust & University of CambridgeCambridgeUK
| | - Angelos Kolias
- Division of Neurosurgery, Department of Clinical NeurosciencesCambridge University Hospitals NHS Foundation Trust & University of CambridgeCambridgeUK
| | - Ivan Timofeev
- Division of Neurosurgery, Department of Clinical NeurosciencesCambridge University Hospitals NHS Foundation Trust & University of CambridgeCambridgeUK
| | - Peter Hutchinson
- Division of Neurosurgery, Department of Clinical NeurosciencesCambridge University Hospitals NHS Foundation Trust & University of CambridgeCambridgeUK
| | - Adel Helmy
- Division of Neurosurgery, Department of Clinical NeurosciencesCambridge University Hospitals NHS Foundation Trust & University of CambridgeCambridgeUK
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Porto Junior S, Meira DA, da Cunha BLB, Fontes JHM, Pustilnik HN, Medrado Nunes GS, Cerqueira GA, Silva da Paz MGD, Alcântara T, Dourado JC, Miranda de Avelar L. Active Versus Passive Drainage Systems for Subdural Hematomas: A Systematic Review and Meta-Analysis. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01229. [PMID: 38967446 DOI: 10.1227/ons.0000000000001252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 04/30/2024] [Indexed: 07/06/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Chronic subdural hematoma (CSDH) management involves various surgical techniques, with drainage systems playing a pivotal role. While passive drainage (PD) and active drainage (AD) are both used, their efficacy remains contentious. Some studies favor PD for lower recurrence rates, while others suggest AD superiority. A systematic review and meta-analysis were conducted to address this controversy, aiming to provide clarity on optimal drainage modalities post-CSDH evacuation. METHODS This systematic review and meta-analysis followed preferred reporting items for systematic reviews guidelines, searching PubMed, Embase, and Web of Science until February 2024. Inclusion criteria focused on studies comparing active vs PD for subdural hematomas. Data extraction involved independent researchers, and statistical analysis was conducted using R software. The assessment of risk of bias was performed using the Risk of Bias in Non-Randomized Studies of Interventions framework and the Risk Of Bias 2 tool. RESULTS In this meta-analysis, involving 1949 patients with AD and 1346 with PD, no significant differences were observed in recurrence rates between the active (13.6%) and passive (16.4%) drainage groups (risk ratio [RR] = 0.87; 95% CI: 0.58-1.31). Similarly, for complications, infection, hemorrhage, and mortality, no significant disparities were found between the 2 drainage modalities. Complication rates were 7.5% for active and 12.6% for PD (RR = 0.74; 95% CI: 0.36-1.52). Infection rates were available for 635 patients of the active group, counting for 2% and 2.6%, respectively (RR = 0.98; 95% CI: 0.24-4.01). Hemorrhage rates were also available for 635 patients of the active group, counting for 1.1% and 2.2%, respectively (RR = 0.44; 95% CI: 0.11-1.81). Mortality rates were 2.7% and 2.5%, respectively (RR = 0.94; 95% CI: 0.61-1.46). CONCLUSION Our study found no significant difference between passive and AD for managing complications, recurrence, infection, hemorrhage, or mortality in CSDH cases. Further large-scale randomized trials are needed for clarity.
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Affiliation(s)
| | - Davi Amorim Meira
- Department of Medicine, Bahiana School of Medicine, Salvador, Bahia, Brazil
| | | | | | | | | | | | | | - Tancredo Alcântara
- Department of Neurosurgery, General Hospital Roberto Santos, Salvador, Bahia, Brazil
- Department of Neurosurgery, NICC-Núcleo Integrado do Cérebro e Coluna, Salvador, Bahia, Brazil
| | - Jules Carlos Dourado
- Department of Neurosurgery, General Hospital Roberto Santos, Salvador, Bahia, Brazil
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Kan P, Fiorella D, Dabus G, Samaniego EA, Lanzino G, Siddiqui AH, Chen H, Khalessi AA, Pereira VM, Fifi JT, Bain MD, Colby GP, Wakhloo AK, Arthur AS. ARISE I Consensus Statement on the Management of Chronic Subdural Hematoma. Stroke 2024; 55:1438-1448. [PMID: 38648281 DOI: 10.1161/strokeaha.123.044129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 01/10/2024] [Indexed: 04/25/2024]
Abstract
ARISE (Aneurysm/AVM/cSDH Roundtable Discussion With Industry and Stroke Experts) organized a one-and-a-half day meeting and workshop and brought together representatives from academia, industry, and government to discuss the most promising approaches to improve outcomes for patients with chronic subdural hematoma (cSDH). The emerging role of middle meningeal artery embolization in clinical practice and the design of current and potential future trials were the primary focuses of discussion. Existing evidence for imaging, indications, agents, and techniques was reviewed, and areas of priority for study and key questions surrounding the development of new and existing treatments for cSDH were identified. Multiple randomized, controlled trials have met their primary efficacy end points, providing high-level evidence that middle meningeal artery embolization is a potent adjunctive therapy to the standard (surgical and nonsurgical) management of neurologically stable cSDH patients in terms of reducing rates of disease recurrence. Pooled data analyses following the formal conclusion and publication of these trials will form a robust foundation upon which guidelines can be strengthened for cSDH treatment modalities and optimal patient selection, as well as delineate future lines of investigation.
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Affiliation(s)
- Peter Kan
- Department of Neurosurgery, The University of Texas Medical Branch, Galveston (P.K.)
| | - David Fiorella
- Department of Neurosurgery, Stony Brook University, NY (D.F.)
| | - Guilherme Dabus
- Interventional Neuroradiology and Neuroendovascular Surgery, Miami Neuroscience Institute and Miami Cardiac and Vascular Institute-Baptist Hospital, FL (G.D.)
| | - Edgar A Samaniego
- Department of Neurology, The University of Iowa Hospitals and Clinics (E.A.S.)
| | | | - Adnan H Siddiqui
- Department of Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, NY (A.H.S.)
| | - Huanwen Chen
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (H.C.)
| | - Alexander A Khalessi
- Department of Neurological Surgery, University of California, San Diego, La Jolla (A.A.K.)
| | - Vitor Mendes Pereira
- Division of Neuroradiology, Department of Medical Imaging and Division of Neurosurgery, Department of Surgery, University Health Network, Toronto Western Hospital, ON, Canada (V.M.P.)
| | - Johanna T Fifi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.T.F.)
| | - Mark D Bain
- Cerebrovascular Center, Departments of Neurology and Neurosurgery, Neurological Institute, Cleveland Clinic Foundation, OH (M.D.B.)
| | - Geoffrey P Colby
- Department of Neurosurgery, University of California Los Angeles David Geffen School of Medicine (G.P.C.)
| | - Ajay K Wakhloo
- Department of Interventional Neuroradiology, Lahey Hospital & Medical Center, Burlington, MA (A.K.W.)
| | - Adam S Arthur
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis (A.S.A.)
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Chen H, Colasurdo M, Malhotra A, Gandhi D, Bodanapally UK. Advances in chronic subdural hematoma and membrane imaging. Front Neurol 2024; 15:1366238. [PMID: 38725642 PMCID: PMC11079242 DOI: 10.3389/fneur.2024.1366238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 03/14/2024] [Indexed: 05/12/2024] Open
Abstract
Chronic subdural hematoma (cSDH) is projected to become the most common cranial neurosurgical disease by 2030. Despite medical and surgical management, recurrence rates remain high. Recently, middle meningeal artery embolization (MMAE) has emerged as a promising treatment; however, determinants of disease recurrence are not well understood, and developing novel radiographic biomarkers to assess hematomas and cSDH membranes remains an active area of research. In this narrative review, we summarize the current state-of-the-art for subdural hematoma and membrane imaging and discuss the potential role of MR and dual-energy CT imaging in predicting cSDH recurrence, surgical planning, and selecting patients for embolization treatment.
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Affiliation(s)
- Huanwen Chen
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States
- Department of Neurology, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Marco Colasurdo
- Department of Interventional Radiology, Oregon Health & Science University, Portland, OR, United States
| | - Ajay Malhotra
- Department of Radiology, Yale New Haven Hospital, New Haven, CT, United States
| | - Dheeraj Gandhi
- Department of Radiology, University of Maryland Medical Center, Baltimore, MD, United States
- Department of Neurology, University of Maryland Medical Center, Baltimore, MD, United States
- Department of Neurosurgery, University of Maryland Medical Center, Baltimore, MD, United States
| | - Uttam K. Bodanapally
- Department of Radiology, University of Maryland Medical Center, Baltimore, MD, United States
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Zawy Alsofy S, Lewitz M, Meyer K, Fortmann T, Wilbers E, Nakamura M, Ewelt C. Retrospective Analysis of Risk Factors for Recurrence of Chronic Subdural Haematoma after Surgery. J Clin Med 2024; 13:805. [PMID: 38337502 PMCID: PMC10856185 DOI: 10.3390/jcm13030805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 01/25/2024] [Accepted: 01/30/2024] [Indexed: 02/12/2024] Open
Abstract
(1) Background: In this study, epidemiological, clinical, therapeutical, and haemostaseological variables were investigated regarding their correlation with the recurrence of chronic subdural haematomas to assess the risk of recurrence more reliably in everyday clinical practice. (2) Methods: In our retrospective study, the electronic records of 90 patients who underwent surgery for a chronic subdural haematoma at our institute between 1 January 2017 and 31 May 2021 were analysed regarding previously defined variables. (3) Results: In the patient collective, 33.33% of the 90 patients experienced a recurrence requiring treatment. The occurrence of a recurrence was not statistically significantly related to age, gender, known alcohol abuse, a specific location, extension over one or both hemispheres, the surgical method, or anticoagulant medication. However, the recurrence was statistically significantly related to haematoma width (p = 0.000007), septation (p = 0.005), and the existence of a coagulation disorder not treated with medication (p = 0.04). (4) Conclusions: In our study, the width of the haematoma, septation, and coagulation disorders not treated with medication were documented as risk factors for the occurrence of a chronic subdural haematoma. Identifying of these risk factors could help in adapting individual therapeutic concepts for chronic subdural haematomas.
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Affiliation(s)
- Samer Zawy Alsofy
- Department of Medicine, Faculty of Health, Witten/Herdecke University, 58448 Witten, Germany; (M.L.); (T.F.); (E.W.)
- Department of Neurosurgery, St. Barbara-Hospital, Academic Hospital of Westfaelische Wilhelms-University Muenster, 59073 Hamm, Germany; (K.M.); (C.E.)
| | - Marc Lewitz
- Department of Medicine, Faculty of Health, Witten/Herdecke University, 58448 Witten, Germany; (M.L.); (T.F.); (E.W.)
- Department of Neurosurgery, St. Barbara-Hospital, Academic Hospital of Westfaelische Wilhelms-University Muenster, 59073 Hamm, Germany; (K.M.); (C.E.)
| | - Kyra Meyer
- Department of Neurosurgery, St. Barbara-Hospital, Academic Hospital of Westfaelische Wilhelms-University Muenster, 59073 Hamm, Germany; (K.M.); (C.E.)
| | - Thomas Fortmann
- Department of Medicine, Faculty of Health, Witten/Herdecke University, 58448 Witten, Germany; (M.L.); (T.F.); (E.W.)
- Department of Neurosurgery, St. Barbara-Hospital, Academic Hospital of Westfaelische Wilhelms-University Muenster, 59073 Hamm, Germany; (K.M.); (C.E.)
| | - Eike Wilbers
- Department of Medicine, Faculty of Health, Witten/Herdecke University, 58448 Witten, Germany; (M.L.); (T.F.); (E.W.)
- Department of Neurosurgery, St. Barbara-Hospital, Academic Hospital of Westfaelische Wilhelms-University Muenster, 59073 Hamm, Germany; (K.M.); (C.E.)
| | - Makoto Nakamura
- Department of Neurosurgery, Academic Hospital Koeln-Merheim, Witten/Herdecke University, 51109 Koeln, Germany;
| | - Christian Ewelt
- Department of Neurosurgery, St. Barbara-Hospital, Academic Hospital of Westfaelische Wilhelms-University Muenster, 59073 Hamm, Germany; (K.M.); (C.E.)
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Tong X, Xue X, Liu A, Qi P. Comparative study on clinical outcomes and cost-effectiveness of chronic subdural hematomas treated by middle meningeal artery embolization and conventional treatment: a national cross-sectional study. Int J Surg 2023; 109:3836-3847. [PMID: 37830938 PMCID: PMC10720801 DOI: 10.1097/js9.0000000000000699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 08/13/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND The authors compared the efficacy and cost-effectiveness of middle meningeal artery embolization (MMAE) and conventional treatment for chronic subdural hematomas (cSDH). METHODS The Nationwide Readmissions Database of 9963 patients (27.2% women) with cSDH between 2016 and 2020 was analyzed. Finally, 9532 patients were included (95.7%, treated conventionally; 4.3%, treated with MMAE). Baseline demographics, comorbidities, adverse events, treatment strategies, and outcomes were compared between patients treated with MMAE and conventional treatment. After propensity score matching, the authors compared primary outcomes, including the 90-day treatment rate, functional outcome, length of hospital stays, and cost. A Markov model estimated lifetime costs and quality-adjusted life years (QALYs) associated with different treatments. The incremental cost-effectiveness ratio (ICER) was calculated to evaluate the base-case scenario. One-way, two-way, and probabilistic sensitivity analyses were performed to evaluate the uncertainty in the results. RESULTS After propensity score matching, MMAE had a lower 90-day retreatment rate (2.6 vs. 9.0%, P =0.001), shorter length of hospital stays (4.61±6.19 vs. 5.73±5.76 days, P =0.037), similar functional outcomes compared (favorable outcomes, 80.9 vs. 74.8%, P =0.224) but higher costs ($119 757.71±90 378.70 vs. $75 745.55±100 701.28, P <0.001) with conventional treatment. MMAE was associated with an additional cost of US$19 280.0 with additional QALY of 1.3. Its ICER was US$15199.8/QALY. CONCLUSION MMAE is more effective in treating cSDH than conventional treatment. Based on real-world data, though MMAE incurs higher overall costs, the Markov model showed it to be cost-effective compared to conventional treatment under the American healthcare system. These comparative and economic analyses further support the consideration of a paradigm shift in cSDH treatment.
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Affiliation(s)
- Xin Tong
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University
| | - Xiaopeng Xue
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University
| | - Aihua Liu
- Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University
| | - Peng Qi
- Department of Neurosurgery, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
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Sayed R, Gross S, Zamarud A, Nie L, Mudhar G, Eikermann M, Rupp S, Kim J, Babar M, Basam M, Yassari R, Gelfand Y. Predictors of mortality in chronic subdural hematoma evacuation. Neurosurg Rev 2023; 46:318. [PMID: 38036800 DOI: 10.1007/s10143-023-02213-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 10/19/2023] [Accepted: 11/05/2023] [Indexed: 12/02/2023]
Abstract
Chronic subdural hematoma (cSDH) is one of the most common types of intracranial hemorrhages, particularly in the elderly. Despite extensive research regarding cSDH diagnosis and treatment, there is conflicting data on predictors of postoperative mortality (POM). We conducted a large retrospective review of patients who underwent a cSDH evacuation at a single urban institution between 2015 and 2022. Data were collected from the electronic medical record on prior comorbidities, anticoagulation use, mental status on presentation, preoperative labs, and preoperative/postoperative imaging parameters. Univariate and multivariate analyses were conducted to analyze predictors of mortality. Mortality during admission for this cohort was 6.1%. Univariate analysis showed the mortality rate was higher in those presenting with a history of dialysis. In addition, those who presented with altered mental status, were intubated, and lower GCS scores had higher rates of POM. Usage of Coumadin was correlated with higher rates of POM. Examination of preoperative labs showed that patients who presented with anemia or thrombocytopenia had higher POM. Imaging data showed that cSDH volume and greatest dimension were correlated with higher rates of POM. Finally, patients that were not extubated postoperatively had higher rates of POM. Multivariate analysis showed that only altered mental status and being not being extubated postoperatively were correlated with a higher risk of mortality. In summation, we demonstrated that altered mental status and failure to extubate were independent predictors or mortality in cSDH evacuation. Interestingly, patient age was not a significant predictor of mortality.
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Affiliation(s)
- Rahman Sayed
- Department of Neurosurgery, Montefiore Medical Center, Bronx, NY, 10461-1900, USA.
| | - Suzanne Gross
- Department of Neurosurgery, Montefiore Medical Center, Bronx, NY, 10461-1900, USA
| | - Aroosa Zamarud
- Department of Neurosurgery, Stanford School of Medicine, Stanford, CA, 94305, USA
| | - Linda Nie
- Department of Neurosurgery, Montefiore Medical Center, Bronx, NY, 10461-1900, USA
| | - Gagandeep Mudhar
- Department of Neurosurgery, Montefiore Medical Center, Bronx, NY, 10461-1900, USA
| | - Matthias Eikermann
- Department of Anesthesiology, Montefiore Medical Center, Bronx, NY, 10461-1900, USA
| | - Samuel Rupp
- Department of Anesthesiology, Montefiore Medical Center, Bronx, NY, 10461-1900, USA
| | - Jinu Kim
- Department of Anesthesiology, Montefiore Medical Center, Bronx, NY, 10461-1900, USA
| | - Mustufa Babar
- Department of Neurosurgery, Montefiore Medical Center, Bronx, NY, 10461-1900, USA
| | - Mudaser Basam
- Department of Neurosurgery, Montefiore Medical Center, Bronx, NY, 10461-1900, USA
| | - Reza Yassari
- Department of Neurosurgery, Montefiore Medical Center, Bronx, NY, 10461-1900, USA
| | - Yaroslav Gelfand
- Department of Neurosurgery, Montefiore Medical Center, Bronx, NY, 10461-1900, USA
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McCann CP, Brandel MG, Wali AR, Steinberg JA, Pannell JS, Santiago-Dieppa DR, Khalessi AA. Safety of middle meningeal artery embolization for treatment of subdural hematoma: A nationwide propensity score matched analysis. J Cerebrovasc Endovasc Neurosurg 2023; 25:380-389. [PMID: 37469029 PMCID: PMC10774674 DOI: 10.7461/jcen.2023.e2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/19/2023] [Accepted: 06/20/2023] [Indexed: 07/21/2023] Open
Abstract
OBJECTIVE Middle meningeal artery embolization (MMAe) has burgeoned as a treatment for chronic subdural hematoma (cSDH). This study evaluates the safety and short-term outcomes of MMAe patients relative to traditional treatment approaches. METHODS In this retrospective large database study, adult patients in the National Inpatient Sample from 2012-2019 with a diagnosis of cSDH were identified. Cost of admission, length of stay (LOS), discharge disposition, and complications were analyzed. Propensity score matching (PSM) was utilized. RESULTS A total of 123,350 patients with cSDH were identified: 63,450 without intervention, 59,435 surgery only, 295 MMAe only, and 170 surgery plus MMAe. On PSM analysis, MMAe did not increase the risk of inpatient complications or prolong the length of stay compared to conservative management (p>0.05); MMAe had higher cost ($31,170 vs. $10,768, p<0.001) than conservative management, and a lower rate of nonroutine discharge (53.8% vs. 64.3%, p=0.024). Compared to surgery, MMAe had shorter LOS (5 vs. 7 days, p<0.001), and lower rates of neurological complications (2.7% vs. 7.1%, p=0.029) and nonroutine discharge (53.8% vs. 71.7%, p<0.001). There was no significant difference in cost (p>0.05). CONCLUSIONS MMAe had similar LOS and decreased odds of adverse discharge with a modest cost increase compared to conservative management. There was no difference in inpatient complications. Compared to surgery, MMAe treatment was associated with decreased LOS and rates of neurological complications and nonroutine discharge. This nationwide analysis supports the safety of MMAe to treat cSDH.
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Affiliation(s)
- Carson P. McCann
- Department of Neurosurgery, University of California, San Diego, CA, USA
| | - Michael G. Brandel
- Department of Neurosurgery, University of California, San Diego, CA, USA
| | - Arvin R. Wali
- Department of Neurosurgery, University of California, San Diego, CA, USA
| | | | - J. Scott Pannell
- Department of Neurosurgery, University of California, San Diego, CA, USA
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Shimohigoshi W, Takase H, Haze T, Kobayashi Y, Manaka H, Kawasaki T, Sakata K, Yamamoto T. Renin-angiotensin-aldosterone system inhibitors as a risk factor for chronic subdural hematoma recurrence: A matter of debate. J Stroke Cerebrovasc Dis 2023; 32:107291. [PMID: 37579641 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 06/28/2023] [Accepted: 08/01/2023] [Indexed: 08/16/2023] Open
Abstract
OBJECTIVES Chronic subdural hematoma (cSDH) is a common central nervous system condition. Recent reports indicate that cSDH affects long-term prognosis; however, its definitive risk factors remain unknown. An antihypertensive drug, renin-angiotensin-aldosterone system inhibitors (RAASi), can affect vascular permeability and cell proliferation processes, which may suppress the recurrence of cSDH. However, several studies have reported negative results to this effect. Therefore, we aimed to evaluate antihypertensive drugs, including RAASi, as risk factors for recurrent cSDH. MATERIALS AND METHODS A total of 203 consecutive cases of surgically treated cSDH were retrospectively reviewed. Clinical and radiological parameters were compared between the groups with and without cSDH recurrence to identify risk factors. RESULTS Of the included cases, 68 (33.5%) used RAASi and 37 (18.2%) developed recurrence within 60 days of surgery. In the multiple logistic regression analysis adjusted by composite risk score, the odds ratios (95% confidence interval) of RAASi, calcium channel blockers, diuretics, β and α blockers, for the recurrent risk of cSDH after surgery were 2.49 (1.16, 5.42), 1.79 (0.84, 3.82), 1.83 (0.62, 4.87), 0.90 (0.28, 2.44), and 0.96 (0.21, 3.20), respectively. The Cox proportional hazard model also demonstrated that RAASi-use was an independent risk factor for cSDH recurrence. CONCLUSIONS Present series suggests RAASi-use as a risk factor for cSDH recurrence, although the role of RAASi-use in cSDH remains debatable. Further studies for deeper understanding of the microenvironment of hematoma and the surroundings are preferable. (235 words).
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Affiliation(s)
- Wataru Shimohigoshi
- Department of Neurosurgery, Yokohama City University Medical Center, Yokohama, Japan
| | - Hajime Takase
- Center for Novel and Exploratory Clinical Trials (Y-NEXT), Yokohama City University Hospital, Yokohama, Japan; Department of Neurosurgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan.
| | - Tatsuya Haze
- Center for Novel and Exploratory Clinical Trials (Y-NEXT), Yokohama City University Hospital, Yokohama, Japan; Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan.; Department of Nephrology and Hypertension, Yokohama City University Medical Center, Yokohama, Japan
| | - Yusuke Kobayashi
- Center for Novel and Exploratory Clinical Trials (Y-NEXT), Yokohama City University Hospital, Yokohama, Japan; Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Hiroshi Manaka
- Department of Neurosurgery, Yokohama City University Medical Center, Yokohama, Japan
| | - Takashi Kawasaki
- Department of Neurosurgery, Yokohama City University Medical Center, Yokohama, Japan
| | - Katsumi Sakata
- Department of Neurosurgery, Yokohama City University Medical Center, Yokohama, Japan
| | - Tetsuya Yamamoto
- Department of Neurosurgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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Yordanov S, Khan S, Stubbs D, Davies B, Santarius T, Hutchinson P, Joannides A. Assessing the accuracy of the International Classification of Disease (ICD) framework in the identification of patients with chronic subdural haematoma from hospital records. Surgeon 2023; 21:e271-e278. [PMID: 36967307 DOI: 10.1016/j.surge.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 02/04/2023] [Accepted: 02/06/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Chronic subdural hematoma (CSDH) is one of the commonest neurosurgical pathologies with an increasing incidence. Observational studies of routine care have demonstrated high perioperative morbidity and approximately 10% mortality at one year. The development, implementation, and evaluation of a potential care framework relies on an accurate and reproducible method of case identification and case ascertainment. With this manuscript, we report on the accuracy of diagnostic ICD codes for identifying patients with CSDH from retrospective electronic data and explore whether basic demographic data could improve the identification of CSDH. METHODS Data were collected retrospectively from the hospital administrative system between 2014 and 2018 of all patients coded with either S065 or I620. Analysis of the ICD codes in identifying patients with CSDH diagnosis was calculated using the caretR package in RStudioR,.and stepwise logistic regression analysis was performed to evaluate the best predictive model for CSDH. RESULTS A total of 1861 patients were identified. Of these, 189 (10.2%) had a diagnosis of non-traumatic SDH (I620) and 1672 (89.8%) traumatic subdural haematomas (S065). Variables that identified CSDH as a diagnosis on univariate logistic regression included male sex (Odds Ratios (OR) - 1.606 (1.197-2.161), elderly age (OR) - 1.023 (1.015-1.032) per year for age (p < 0.001) and shorter length of hospital stay. Using stepwise regression against AIC the best model to predict CSDH included male sex, older age, and shorter LOS. The calculated sensitivity for identifying CSDH with the model is 88.4% with a specificity of 84.5% and PPV of 87.9%. CONCLUSION CSDH is a common neurosurgical pathology with increasing incidence and ongoing unmet clinical need. We demonstrate that case ascertainment for research purposes can be improved with the incorporation of additional demographic data but at the expense of significant case exclusion.
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Affiliation(s)
- Stefan Yordanov
- Academic Division of Neurosurgery, Addenbrookes' Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Shuaib Khan
- Academic Division of Neurosurgery, Addenbrookes' Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Danial Stubbs
- Academic Division of Neurosurgery, Addenbrookes' Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Benjamin Davies
- Academic Division of Neurosurgery, Addenbrookes' Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
| | - Thomas Santarius
- Academic Division of Neurosurgery, Addenbrookes' Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Peter Hutchinson
- Academic Division of Neurosurgery, Addenbrookes' Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Alexis Joannides
- Academic Division of Neurosurgery, Addenbrookes' Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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11
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Watanabe R, Ueno K, Nomura Y, Kinoshita S, Sasaki T, Yanagiya K, Fujiwara N, Katagai T, Katayama K, Naraoka M, Hasegawa S, Shimamura N, Saitoh A. Verification of a Three-day Hospitalization Protocol for Chronic Subdural Hematoma Surgery. Neurol Med Chir (Tokyo) 2023; 63:375-379. [PMID: 37380450 PMCID: PMC10482484 DOI: 10.2176/jns-nmc.2022-0344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 04/17/2023] [Indexed: 06/30/2023] Open
Abstract
Chronic subdural hematoma (CSH) is predominantly a disease of the elderly. Aging societies in advanced countries are seeing the number of CSH cases increasing. We applied a three-day hospitalization protocol for CSH surgery to reduce healthcare costs and more efficiently manage hospital beds. We investigated the clinical factors that influenced prolonged hospitalization. From January 2015 to December 2020, we performed irrigation, evacuation, and drainage of CSH cases in 221 consecutive patients. The χ2 test and logistic regression analysis were conducted to detect clinical factors influencing prolonged hospitalization. A p-value below 0.05 was considered statistically significant. Applying a three-day hospitalization protocol showed no adverse outcomes. Fifty-two (24%) of 221 patients experienced prolonged hospitalization. The χ2 test showed that female gender, atrial fibrillation, alcohol abuse, preoperative consciousness level, verbal function disturbance, and perioperative activities of daily living were significantly related to prolonged hospitalization. Female gender, atrial fibrillation, and alcohol abuse were significant factors in the logistic regression analysis. A three-day hospitalization protocol for CSH is suitable for patient care; however, particular attention needs to be focused on the female gender, atrial fibrillation, and alcohol abuse, all three of which prolong hospitalization.
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Affiliation(s)
- Ryota Watanabe
- Department of Neurosurgery, Hirosaki University Graduate School of Medicine, Hirosaki
| | - Kota Ueno
- Department of Neurosurgery, Hirosaki University Graduate School of Medicine, Hirosaki
| | - Yu Nomura
- Department of Neurosurgery, Hirosaki University Graduate School of Medicine, Hirosaki
| | - Shohei Kinoshita
- Department of Neurosurgery, Hirosaki University Graduate School of Medicine, Hirosaki
| | - Takao Sasaki
- Department of Neurosurgery, Hirosaki University Graduate School of Medicine, Hirosaki
| | - Keita Yanagiya
- Department of Neurosurgery, Hirosaki University Graduate School of Medicine, Hirosaki
| | - Nozomi Fujiwara
- Department of Neurosurgery, Hirosaki University Graduate School of Medicine, Hirosaki
| | | | - Kosuke Katayama
- Department of Neurosurgery, Hirosaki University Graduate School of Medicine, Hirosaki
| | - Masato Naraoka
- Department of Neurosurgery, Hirosaki University Graduate School of Medicine, Hirosaki
| | - Seiko Hasegawa
- Department of Disaster and Critical Care Medicine, Hirosaki University Graduate School of Medicine
| | | | - Atsushi Saitoh
- Department of Neurosurgery, Hirosaki University Graduate School of Medicine, Hirosaki
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12
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Melander N, Sönnerqvist C, Olivecrona M. Non-surgical patient characteristics best predict outcome after 6 months in patients surgically treated for chronic subdural haematoma. J Clin Neurosci 2023; 114:151-157. [PMID: 37429160 DOI: 10.1016/j.jocn.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 06/18/2023] [Accepted: 07/01/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND Chronic subdural haematoma (CSDH) is one of the most common conditions encountered in neurosurgical practice. After surgery, the patients often improve dramatically; but their long-term outcome is more uncertain. The purpose of this study was to investigate predictors of outcome 6 months after surgery. METHODS Retrospective data were collected on patients in Orebro County, Sweden, who had undergone surgery for CSDH at the Orebro University Hospital between 2013 and 2019. The outcomes were defined as favourable or unfavourable in terms of the modified Rankin Scale (mRS). A favourable outcome was defined as either mRS 0-2 or an unchanged mRS score in patients scoring 3-5 before surgery. From the variables in the data collected, a multiple logistic regression model was constructed. RESULTS The study comprised 180 patients, of whom 134 (74.4%) were male. Median age was 79.2 years (IQR 71.7-85.5), and 129 (71.7%) patients had a favourable outcome at 6 months. In the group with an unfavourable outcome, 18 (10%) had died and 33 (18.3%) had either lost their independence in daily living or become somewhat less independent. The final multiple logistic regression model consisted of pre-surgery variables only: age (OR 0.92, 95% CI 0.87-0.97), CRP (OR 0.96, 95% CI 0.94-0.99), GCS > 13 (OR 3.66, 95% CI 1.09-12.3), Hb (OR 1.03, 95% CI 1.00-1.05), and ASA score < 3 (OR 2.58, 95% CI 0.98-6.79). The whole model had an AUC of 0.88. CONCLUSION CSDH requiring surgery is associated with high morbidity and mortality at 6 months after surgery. Age, CRP, GCS, Hb and ASA score on admission for surgery are the variables that best predicts outcome. This knowledge can help to identify the patients at greatest risk for an unfavourable outcome, who may need additional support from the health care system. UNSTRUCTURED ABSTRACT Chronic subdural haematoma (CSDH) is one of the most common conditions encountered in neurosurgical practice. After surgery, the patients often improve dramatically; but their long-term outcome is more uncertain. The purpose of this study was to investigate predictors of outcome, in terms of the modified Rankin Scale (mRS), 6 months after surgery. The study comprised 180 patients, of whom 134 (74.4%) were male. Median age was 79.2 years (IQR 71.7-85.5), and 129 (71.7%) patients had a favourable outcome at 6 months. In the group with an unfavourable outcome, 18 (10%) had died and 33 (18.3%) had either lost their independence in daily living or become somewhat less independent. The final multiple logistic regression model consisted of pre-surgery variables only: age (OR 0.92, 95% CI 0.87-0.97), CRP (OR 0.96, 95% CI 0.94-0.99), GCS > 13 (OR 3.66, 95% CI 1.09-12.3), Hb (OR 1.03, 95% CI 1.00-1.05), and ASA score < 3 (OR 2.58, 95% CI 0.98-6.79). The whole model had an AUC of 0.88. In conclusion, CSDH requiring surgery is associated with high morbidity and mortality at 6 months after surgery. Age, CRP, GCS, Hb and ASA score on admission for surgery are the variables that best predicts outcome. This knowledge can help to identify the patients at greatest risk for an unfavourable outcome, who may need additional support from the health care system.
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Affiliation(s)
- Nils Melander
- Department of Neurology, Faculty of Medicine and Health, Örebro University, SE-701 82 Örebro, Sweden.
| | - Caroline Sönnerqvist
- Department of Paediatrics, Faculty of Medicine and Health, Örebro University, SE-701 82 Örebro, Sweden
| | - Magnus Olivecrona
- Department of Neurosurgery, Faculty of Medicine and Health, Örebro University, SE-701 82 Örebro, Sweden
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13
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Gillespie CS, Fung KW, Alam AM, Yanez Touzet A, Dhesi J, Edlmann E, Coles J, Menon DK, Hutchinson PJ, Stubbs DJ, Davies BM. How does research activity align with research need in chronic subdural haematoma: a gap analysis of systematic reviews with end-user selected knowledge gaps. Acta Neurochir (Wien) 2023:10.1007/s00701-023-05618-2. [PMID: 37249690 DOI: 10.1007/s00701-023-05618-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 04/30/2023] [Indexed: 05/31/2023]
Abstract
BACKGROUND Chronic subdural haematoma (CSDH) is increasingly common. Although treatment is triaged and provided by neurosurgery, the role of non-operative care, alongside observed peri-operative morbidity and patient complexity, suggests that optimum care requires a multi-disciplinary approach. A UK consortium (Improving Care in Elderly Neurosurgery Initiative [ICENI]) has been formed to develop the first comprehensive clinical practice guideline. This starts by identifying critical questions to ask of the literature. The aim of this review was to consider whether existing systematic reviews had suitably addressed these questions. METHODS Critical research questions to inform CSDH care were identified using multi-stakeholder workshops, including patient and public representation. A CSDH umbrella review of full-text systematic reviews and meta-analysis was conducted in accordance with the PRISMA statement (CRD42022328562). Four databases were searched from inception up to 30 April 2022. Review quality was assessed using AMSTAR-2 criteria, mapped to critical research questions. RESULTS Forty-four critical research questions were identified, across 12 themes. Seventy-three articles were included in the umbrella review, comprising 206,369 patients. Most reviews (86.3%, n=63) assessed complications and recurrence after surgery. ICENI themes were not addressed in current literature, and duplication of reviews was common (54.8%, n=40). AMSTAR-2 confidence rating was high in 7 (9.6%) reviews, moderate in 8 (11.0%), low in 10 (13.7%) and critically low in 48 (65.8%). CONCLUSIONS The ICENI themes have yet to be examined in existing secondary CSDH literature, and a series of new reviews is now required to address these questions for a clinical practice guideline. There is a need to broaden and redirect research efforts to meet the organisation of services and clinical needs of individual patients.
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Affiliation(s)
- Conor S Gillespie
- Department of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, CB2 0SZ, Cambridge, UK.
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK.
| | - Kwan Wai Fung
- Department of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, CB2 0SZ, Cambridge, UK
| | - Ali M Alam
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Alvaro Yanez Touzet
- Department of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, CB2 0SZ, Cambridge, UK
- School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Jugdeep Dhesi
- Department of Ageing and Health, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Ellie Edlmann
- Department of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, CB2 0SZ, Cambridge, UK
| | - Jonathan Coles
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
| | - David K Menon
- Department of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, CB2 0SZ, Cambridge, UK
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Peter J Hutchinson
- Department of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, CB2 0SZ, Cambridge, UK
| | - Daniel J Stubbs
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Benjamin M Davies
- Department of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, CB2 0SZ, Cambridge, UK
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14
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Biswas S, MacArthur J, Sarkar V, Thompson H, Saleemi M, George KJ. Development and Validation of the Chronic Subdural HematOma Referral oUtcome Prediction Using Statistics (CHORUS) Score: A Retrospective Study at a National Tertiary Center. World Neurosurg 2023; 170:e724-e736. [PMID: 36442777 DOI: 10.1016/j.wneu.2022.11.097] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 11/21/2022] [Accepted: 11/22/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Chronic subdural hematoma (CSDH) is a common neurosurgical condition with an increasing rate of patient referrals. CSDH referral decision-making is a subjective clinical process, and our aim was to develop a simple scoring system capable of acting as a decision support tool aiding referral triage. METHODS A single tertiary center retrospective case series analysis of all CSDH patient referrals from 2015 to 2020 was conducted. Ten independent variables used in the referral process were analyzed to predict the binary outcome of either accepting or rejecting the CSDH referral. Following feature selection analysis, a multivariable scoring system was developed and evaluated. RESULTS 1500 patient referrals were included. Stepwise multivariable logistic and least absolute shrinkage and selection operator regression identified age <85 years, the presence of headaches, dementia, motor weakness, radiological midline shift, a reasonable premorbid quality of life, and a large sized hematoma to be statistically significant predictors of CSDH referral acceptance (P <0.04). These variables derived a scoring system ranging from -9 to 6 with an optimal cut-off for referral acceptance at any score >1 (P <0.0001). This scoring system demonstrated optimal calibration (brier score loss = 0.0552), with a score >1 predicting referral acceptance with an area under the curve of 0.899 (0.876-0.922), a sensitivity of 83.838% (76.587-91.089), and a specificity of 96.000% (94.080-97.920). CONCLUSIONS Certain patient specific clinical and radiological characteristics can predict the acceptance or rejection of a CSDH referral. Considering the precision of this scoring system, it has the potential for effectively triaging CSDH referrals.
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Affiliation(s)
- Sayan Biswas
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Joshua MacArthur
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Ved Sarkar
- Division of Computer Information Systems, De Anza College, Cupertino, California, USA
| | - Helena Thompson
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Mohammad Saleemi
- Department of Neurosurgery, Salford Royal Hospital, Manchester, UK
| | - K Joshi George
- Department of Neurosurgery, Salford Royal Hospital, Manchester, UK.
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15
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Lin MS. Subdural Lesions Linking Additional Intracranial Spaces and Chronic Subdural Hematomas: A Narrative Review with Mutual Correlation and Possible Mechanisms behind High Recurrence. Diagnostics (Basel) 2023; 13:diagnostics13020235. [PMID: 36673045 PMCID: PMC9857428 DOI: 10.3390/diagnostics13020235] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 12/11/2022] [Accepted: 01/05/2023] [Indexed: 01/10/2023] Open
Abstract
The purpose of this study was two-fold. The first was to investigate the pathologic mechanisms underlying the formation of subdural fluid collection, an umbrella term referring to a condition commonly seen in the clinical setting. Accumulation of the cerebrospinal fluid (CSF) in the subdural space can be referred to in this disease category, disregarding the underlying source of the subdural fluid. However, in these two clinical situations, especially after trauma or brain surgery, fluid collection from the subarachnoid space (subdural hygroma) or from the ventricle to the subarachnoid space and infusion into the subdural space (external hydrocephalus), surgical management of critical patients may adopt the strategies of burr-hole, subduroperitoneal shunt, or ventriculoperitoneal shunt, which present distinctly different thoughts. Crucially, the former can be further transformed into chronic subdural hematoma (CSDH). The second significant theme was the pathogenesis of CSDH. Once the potential dural border cell (DBC) layer is separated such as if a wound is formed, the physiological mechanisms that seem to promote wound healing will resume in the subdural space as follows: coagulation, inflammation, fibroblast proliferation, neovascularization, and fibrinolysis. These aptly correspond to several key characteristics of CSDH formation such as the presence of both coagulation and fibrinolysis signals within the clot, neomembrane formation, angiogenesis, and recurrent bleeding, which contribute to CSDH failing to coagulate and absorb easily. Such a complexity of genesis and the possibility of arising from multiple pathological patterns provide a reasonable explanation for the high recurrence rate, even after surgery. Among the various complex and clinically challenging subdural lesions, namely, CSDH (confined to the subdural space alone), subdural hygroma (linked in two spaces), and external hydrocephalus (linked in three spaces), the ability to fully understand the different pathological mechanisms of each, differentiate them clinically, and devote more interventional strategies (including anti-inflammatory, anti-angiogenic, and anti-fibrinolysis) will be important themes in the future.
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Affiliation(s)
- Muh-Shi Lin
- Division of Neurosurgery, Department of Surgery, Kuang Tien General Hospital, Taichung 43303, Taiwan; ; Tel.: +886-4-2665-1900
- Department of Biotechnology and Animal Science, College of Bioresources, National Ilan University, Yilan 26047, Taiwan
- Department of Biotechnology, College of Medical and Health Care, Hung Kuang University, Taichung 43302, Taiwan
- Department of Health Business Administration, College of Medical and Health Care, Hung Kuang University, Taichung 43302, Taiwan
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16
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Henry J, Amoo M, Kissner M, Deane T, Zilani G, Crockett MT, Javadpour M. Management of Chronic Subdural Hematoma: A Systematic Review and Component Network Meta-analysis of 455 Studies With 103 645 Cases. Neurosurgery 2022; 91:842-855. [PMID: 36170165 DOI: 10.1227/neu.0000000000002144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 07/14/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Chronic subdural hematoma (CSDH) is a common neurosurgical condition with a high risk of recurrence after treatment. OBJECTIVE To assess and compare the risk of recurrence, morbidity, and mortality across various treatments for CSDH. METHODS A systematic review and meta-analysis was performed. PubMed/MEDLINE, EMBASE, SCOPUS, and Web of Science were searched from January 01, 2000, to July 07, 2021. The primary outcome was recurrence, and secondary outcomes were morbidity and mortality. Component network meta-analyses (CNMAs) were performed for surgical and medical treatments, assessing recurrence and morbidity. Incremental risk ratios (iRRs) with 95% CIs were estimated for each component. RESULTS In total, 12 526 citations were identified, and 455 studies with 103 645 cases were included. Recurrence occurred in 11 491/93 525 (10.8%, 95% CI 10.2-11.5, 418 studies) cases after surgery. The use of a postoperative drain (iRR 0.53, 95% CI 0.44-0.63) and middle meningeal artery embolization (iRR 0.19, 95% CI 0.05-0.83) reduced recurrence in the surgical CNMA. In the pharmacological CNMA, corticosteroids (iRR 0.47, 95% CI 0.36-0.61) and surgical intervention (iRR 0.11, 95% CI 0.07-0.15) were associated with lower risk. Corticosteroids were associated with increased morbidity (iRR 1.34, 95% CI 1.05-1.70). The risk of morbidity was equivalent across surgical treatments. CONCLUSION Recurrence after evacuation occurs in approximately 10% of cSDHs, and the various surgical interventions are approximately equivalent. Corticosteroids are associated with reduced recurrence but also increased morbidity. Drains reduce the risk of recurrence, but the position of drain (subdural vs subgaleal) did not influence recurrence. Middle meningeal artery embolization is a promising treatment warranting further evaluation in randomized trials.
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Affiliation(s)
- Jack Henry
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland
| | - Michael Amoo
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland.,Department of Neurosurgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Malia Kissner
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Thomas Deane
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Gulam Zilani
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland
| | - Matthew T Crockett
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland.,Department of Neuroradiology, Beaumont Hospital, Dublin, Ireland
| | - Mohsen Javadpour
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland.,Department of Neurosurgery, Royal College of Surgeons in Ireland, Dublin, Ireland.,Department of Academic Neurology, Trinity College Dublin, Dublin, Ireland
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17
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Shaftel KA, Jubran JH, Cole TS, Little AS. Nationwide Readmission Rates and Hospital Charges for Patients With Surgical Evacuation of Nontraumatic Subdural Hematomas: Part 2-Burr Hole Craniostomy. Neurosurgery 2022; 91:892-899. [PMID: 36053076 DOI: 10.1227/neu.0000000000002119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 06/20/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Nontraumatic subdural hematoma (SDH) is a common neurological disease that causes extensive morbidity and mortality. Craniotomy or burr hole craniostomy (BHC) is indicated for symptomatic lesions, but both are associated with high recurrence rates. Although extensive research exists on postoperative complications after BHCs, few studies have examined the underlying causes and predictors of unplanned 30-day hospital readmissions at the national level. OBJECTIVE To compare causes for hospital readmission within 30 days after surgical SDH evacuation with BHC and evaluate readmission rates and independent predictors of readmission. METHODS This retrospective cohort observational study was designed using the Nationwide Readmissions Database. We identified patients who had undergone BHC for SDH evacuation (2010-2015). National estimates and variances within the cohort were calculated after stratifying, hospital clustering, and weighting variables. RESULTS We analyzed 2753 patients who had BHC for SDH evacuation: 675 (24.5%) had at least one 30-day readmission. Annual readmission rates did not vary across the study period ( P = .60). The most common cause of readmission was recurrent SDH (n = 630, 93.3%), and the next most common was postoperative infection (n = 12, 1.8%). Comorbidities significantly associated with readmission included fluid and electrolyte disorders, chronic blood loss anemia, chronic obstructive pulmonary disease, depression, liver disease, and psychosis ( P ≤ .04), but statistically significant independent predictors for readmission included only chronic obstructive pulmonary disease and fluid and electrolyte disorders ( P ≤ .007). CONCLUSION These national trends in 30-day readmission rates after nontraumatic SDH evacuation by BHC not otherwise published provide quality benchmarks that can aid national quality improvement efforts.
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Affiliation(s)
- Kelly A Shaftel
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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18
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Reith W, Garner M. [Middle meningeal artery embolization for chronic subdural hematomas]. RADIOLOGIE (HEIDELBERG, GERMANY) 2022; 62:641-647. [PMID: 35789427 DOI: 10.1007/s00117-022-01038-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/09/2022] [Indexed: 01/22/2023]
Abstract
The treatment of chronic subdural hematoma (cSDH) represents a challenge due to high recurrence rates (2-37%). One possible treatment option is middle meningeal artery (MMA) embolization as an alternative to surgery. In contrast to acute SDH, which is caused by a rupture of the bridging veins, cSDH has a different pathomechanism. Injury to the so-called dural boundary cell layer results in an intermittent or continuous cycle of cell proliferation, angiogenesis, secretion, and bleeding due to rupture of newly formed vessels within the SDH membrane. This membrane is supplied by the MMA. Embolization of the MMA leads to resorption of the cSDH. The results published so far regarding MMA embolization as sole therapy or in combination with surgical treatment are encouraging with a long-term success rate of up to 90%.
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Affiliation(s)
- Wolfgang Reith
- Klinik für Diagnostische und Interventionelle Neuroradiologie, Universitätsklinikum des Saarlandes, Kirrberger Str., 66424, Homburg-Saar, Deutschland.
| | - Malvina Garner
- Klinik für Diagnostische und Interventionelle Neuroradiologie, Universitätsklinikum des Saarlandes, Kirrberger Str., 66424, Homburg-Saar, Deutschland
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19
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Hatfield JK, Komisarow JM. Commentary: Randomized Trial Comparing Burr Hole Craniostomy, Minicraniotomy, and Twist Drill Craniostomy for Treatment of Chronic Subdural Hematoma. Neurosurgery 2022; 91:e100-e101. [DOI: 10.1227/neu.0000000000002076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 05/25/2022] [Indexed: 11/19/2022] Open
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20
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Posti JP, Luoto TM, Sipilä JOT, Rautava P, Kytö V. Prognosis of patients with operated chronic subdural hematoma. Sci Rep 2022; 12:7020. [PMID: 35488040 PMCID: PMC9054845 DOI: 10.1038/s41598-022-10992-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 04/14/2022] [Indexed: 12/11/2022] Open
Abstract
Chronic subdural hematoma (cSDH), previously considered fairly benign and easy to treat, is now viewed a possible sign of incipient clinical decline. We investigated case-fatality, excess fatality and need for reoperations following operated cSDH in a nationwide setting focusing on patient-related characteristics. Finnish nationwide databases were searched for all admissions with operated cSDH as well as later deaths in adults (≥ 16 years) during 2004–2017. There were 8539 patients with an evacuated cSDH (68% men) with a mean age of 73.0 (± 12.8) years. During the follow-up, 3805 (45%) patients died. In-hospital case-fatality was 0.7% (n = 60) and 30-day case-fatality 4.2% (n = 358). The 1-year case-fatality was 14.3% (95% CI = 13.4–15.2%) among men and 15.3% (95% CI = 14.0–16.7%) among women. Comorbidity burden, older age, and alcoholism were significantly associated with fatality. One-year excess fatality rate compared to general Finnish population was 9.1% (95% CI = 8.4–9.9) among men and 10.3% (95% CI = 9.1–11.4) among women. Highest excess fatality was observed in the oldest age group in both genders. Reoperation was needed in 19.4% (n = 1588) of patients. Older age but not comorbidity burden or other patient-related characteristics were associated with increased risk for reoperation. The overall case-fatality and need for reoperations declined during the study era. Comorbidities should be considered when care and follow-up are planned in patients with cSDH. Our findings underpin the perception that the disease is more dangerous than previously thought and causes mortality in all exposed age groups: even a minor burden of comorbidities can be fatal in the post-operative period.
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Affiliation(s)
- Jussi P Posti
- Neurocenter, Department of Neurosurgery and Turku Brain Injury Center, Turku University Hospital and University of Turku, P.O. Box 52, 20521, Turku, Finland.
| | - Teemu M Luoto
- Department of Neurosurgery, Tampere University Hospital and Tampere University, Tampere, Finland
| | - Jussi O T Sipilä
- Clinical Neurosciences, University of Turku, Turku, Finland.,Department of Neurology, Siun Sote, North Karelia Central Hospital, Joensuu, Finland
| | - Päivi Rautava
- Clinical Research Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Ville Kytö
- Heart Centre and Center for Population Health Research, Turku University Hospital and University of Turku, Turku, Finland.,Research Center of Applied and Preventive Cardiovascular Medicine, University of Turku, Turku, Finland.,Center for Population Health Research, Turku University Hospital and University of Turku, Turku, Finland.,Administative Center, Hospital District of Southwest Finland, Turku, Finland
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Weigel R, Schilling L, Krauss JK. The pathophysiology of chronic subdural hematoma revisited: emphasis on aging processes as key factor. GeroScience 2022; 44:1353-1371. [DOI: 10.1007/s11357-022-00570-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 04/07/2022] [Indexed: 12/24/2022] Open
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Tang G, Chen J, Li B, Fang S. The Efficacy of Adjuvant Corticosteroids in Surgical Management of Chronic Subdural Hematoma: A Systematic Review and Meta-Analysis. Front Neurol 2022; 12:744266. [PMID: 35095713 PMCID: PMC8792049 DOI: 10.3389/fneur.2021.744266] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 12/20/2021] [Indexed: 11/25/2022] Open
Abstract
Objective: This systematic review aimed to assess the efficacy of adjuvant corticosteroids in managing patients with chronic subdural hematoma (CSDH) undergoing surgical intervention. Methods: We searched for eligible studies electronically on the databases of PubMed, Embase, and Google Scholar. The last date of the search was 15th Jun 2021. Outcomes were pooled to calculate risk ratios (RR) with 95% confidence intervals (CI). Results: Eleven studies were included. Four of them were randomized controlled trials (RCTs). Six studies reported data on good neurological outcomes but with variable definitions. Combining all studies, we noted no statistically significant difference in good neurological outcome with the use of adjuvant corticosteroids (RR: 0.91 95% CI: 0.74, 1.12 I2 = 92% p = 0.39). Similar results were obtained on subgroup analysis based on definition and study type. However, the use of adjuvant corticosteroids was associated with a significantly reduced risk of recurrence (RR: 0.51 95% CI: 0.40, 0.64 I2 = 0% p < 0.0001). The meta-analysis also demonstrated no statistically significant difference in mortality rates with the use of adjuvant corticosteroids (RR: 1.01 95% CI: 0.47, 2.21 I2 = 76% p = 0.97). The results did not differ between RCTs and non-RCTs. Limited studies reported data on complications, and pooled analysis indicated no significant increase in infectious, gastrointestinal, and neurological complications with the use of adjuvant corticosteroids. Conclusion: The use of corticosteroids with surgery for CSDH might be associated with a reduction in recurrence rate. However, corticosteroids do not improve functional outcomes or mortality rates. Future studies should assess the impact of different corticosteroid regimens on patient outcomes, and should use standardized reporting of neurological outcomes with uniform follow-up duration.
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Mortality after chronic subdural hematoma is associated with frailty. Acta Neurochir (Wien) 2022; 164:3133-3141. [PMID: 36173514 PMCID: PMC9705486 DOI: 10.1007/s00701-022-05373-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 09/17/2022] [Indexed: 02/01/2023]
Abstract
PURPOSE Chronic subdural hematoma (CSDH) is a common neurological disease often affecting the elderly. Long-term excess mortality for patients after CSDH has been suggested but causes of death are unknown. We hypothesize that excess mortality of CSDH patients is related to frailty. In this article, we describe mortality rates and causes of death of CSDH patients compared with the general population and assess the association of frailty with mortality. METHODS A cohort study in which consecutive CSDH patients were compared to the general population regarding mortality rates. Furthermore, the association of six frailty indicators (cognitive problems, frequent falling, unable to live independently, unable to perform daily self-care, use of benzodiazepines or psychotropic drugs, and number of medications) with mortality was assessed. RESULTS A total of 1307 CSDH patients were included, with a mean age of 73.7 (SD ± 11.4) years and 958 (73%) were male. Median follow-up was 56 months (range: 0-213). Compared with controls CSDH patients had a hazard ratio for mortality of 1.34 (95% CI: 1.2-1.5). CSDH patients more often died from cardiovascular diseases (37% vs. 30%) and falls (7.2% vs. 3.7%). Among CSDH patients frequent falling (HR 1.3; 95% CI: 1.0-1.7), inability to live independently (HR 1.4, 95% CI: 1.1-1.8), inability to perform daily self-care (HR 1.5; 95% CI: 1.1-1.9), and number of medications used (HR 1.0; 95% CI: 1.0-1.1) were independently associated with mortality. CONCLUSIONS CSDH patients have higher mortality rates than the general population. Frailty in CSDH patients is associated with higher mortality risk. More attention for the frailty of CSDH patients is warranted.
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Kerttula S, Huttunen J, Leinonen V, Kämäräinen OP, Danner N. The effect of antithrombotic therapy on the recurrence and outcome of chronic subdural hematoma after burr-hole craniostomy in a population-based cohort. Acta Neurochir (Wien) 2022; 164:2699-2708. [PMID: 35972559 PMCID: PMC9519695 DOI: 10.1007/s00701-022-05337-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 08/02/2022] [Indexed: 01/26/2023]
Abstract
PURPOSE To study the effect of antithrombotic therapy (ATT) on the outcome of operatively treated chronic subdural hematomas (CSDH). METHODS A retrospective population-based cohort study from Eastern Finland including all adult patients who underwent a burr-hole craniostomy (BHC) for CSDH during 2016 and 2017. The follow-up time for recurrence was 6 months and for mortality 3 years. RESULTS A total of 301 CSDH patients were included in the study. ATT (antithrombotic therapy; antiplatelet or anticoagulant medication) was used by 164 patients (54.5%) at the time of diagnosis. The hematoma was bilateral in 102 patients (33.9%). Forty-seven patients (15.8%) encountered hematoma recurrence. Bilateral CSDHs required reoperations more often than unilateral hematomas (12.6% vs. 22.0%; p = 0.036) regardless of the primary operation (uni- or bilateral). A bivariate logistic regression analysis showed that bilateral hematoma (OR 1.918; 95% CI 1.013-3.630; p = 0.045) and male gender (OR 2.363; 95% CI 1.089-5.128; p = 0.030) independently predicted hematoma recurrence. The overall three-year mortality was 27.9%. The use of ATT was not associated with CSDH recurrence, and the length of the temporary postoperative ATT discontinuation did not correlate with the rate of thromboembolic events. CONCLUSIONS ATT did not affect CSDH recurrence in our study population, and the duration of the temporary postoperative ATT discontinuation was not associated with the rate of thromboembolic complications. Male gender and bilateral hematomas were more frequently associated with recurrences.
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Affiliation(s)
- Santtu Kerttula
- Institute of Clinical Medicine - Neurosurgery, University of Eastern Finland, Kuopio, Finland.
| | - Jukka Huttunen
- Neurocenter - Neurosurgery, Kuopio University Hospital, Kuopio, Finland
| | - Ville Leinonen
- Institute of Clinical Medicine - Neurosurgery, University of Eastern Finland, Kuopio, Finland
- Neurocenter - Neurosurgery, Kuopio University Hospital, Kuopio, Finland
| | - Olli-Pekka Kämäräinen
- Institute of Clinical Medicine - Neurosurgery, University of Eastern Finland, Kuopio, Finland
- Neurocenter - Neurosurgery, Kuopio University Hospital, Kuopio, Finland
| | - Nils Danner
- Neurocenter - Neurosurgery, Kuopio University Hospital, Kuopio, Finland
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Dicpinigaitis AJ, Al-Mufti F, Cooper JB, Faraz Kazim S, Couldwell WT, Schmidt MH, Gandhi CD, Cole CD, Bowers CA. Nationwide trends in middle meningeal artery embolization for treatment of chronic subdural hematoma: A population-based analysis of utilization and short-term outcomes. J Clin Neurosci 2021; 94:70-75. [PMID: 34863465 DOI: 10.1016/j.jocn.2021.10.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 09/29/2021] [Accepted: 10/03/2021] [Indexed: 11/29/2022]
Abstract
Middle meningeal artery (MMA) embolization represents a promising novel treatment modality for chronic subdural hematoma (cSDH), yet utilization and efficacy data are limited. This study evaluates the utilization and short-term outcomes of MMA embolization for cSDH treatment in a large national inpatient registry. cSDH patients treated with MMA embolization and/or surgical evacuation (craniotomy/burr hole drainage) were identified using the National Inpatient Sample (NIS) during 2012-2018 period. Temporal trends, complications, and discharge disposition were evaluated, and propensity score matching was implemented for adjusted comparisons and to mitigate confounding by indication. Among 60,045 cSDH patients identified, 390 (0.6%) underwent MMA embolization. Embolized patients presented more with high acute illness severity subclasses in comparison with surgically evacuated patients (53% vs. 34%, p = 0.004) yet did not experience any procedure-related hemorrhagic or ischemic complications. Although discharge disposition did not differ from those surgically managed, embolized patients had longer mean hospital stays (13 vs. 8 days, p = 0.023) and accrued greater hospital charges (p < 0.001). Following propensity adjustment, length of stay and charges remained greater in the embolization cohort, yet rates of routine discharge increased appreciably (40% vs. 30%, p = 0.141) relative to surgically treated cSDH patients. The utilization of embolization increased exponentially after 2015, reaching an apex in 2018 (3.7% of treated cSDH). This population-based national assessment demonstrates exponential increases in utilization of MMA embolization for cSDH treatment in recent years. Embolized patients had uncomplicated clinical courses and similar discharge dispositions as surgical evacuation patients. Large-scale prospective trials are warranted to further assess the efficacy of this modality.
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Affiliation(s)
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Jared B Cooper
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Syed Faraz Kazim
- Depertment of Neurosurgery, University of New Mexico, Albuquerque, NM, USA
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Meic H Schmidt
- Depertment of Neurosurgery, University of New Mexico, Albuquerque, NM, USA
| | - Chirag D Gandhi
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Chad D Cole
- Depertment of Neurosurgery, University of New Mexico, Albuquerque, NM, USA
| | - Christian A Bowers
- Depertment of Neurosurgery, University of New Mexico, Albuquerque, NM, USA.
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Zolfaghari S, Bartek J, Strom I, Djärf F, Wong SS, Ståhl N, Jakola AS, Nittby Redebrandt H. Burr hole craniostomy versus minicraniotomy in chronic subdural hematoma: a comparative cohort study. Acta Neurochir (Wien) 2021; 163:3217-3223. [PMID: 34328561 PMCID: PMC8520513 DOI: 10.1007/s00701-021-04902-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 06/07/2021] [Indexed: 11/29/2022]
Abstract
Background Chronic subdural hematoma (CSDH) is one of the most common neurosurgical diseases. In surgical management of CSDH, there is a lack of standardized guidelines concerning surgical techniques and a lack of consensus on which technique(s) are optimal. Neurosurgical centers have shown a wide variation in surgical techniques. The purpose of this study was to compare two different surgical techniques, one burr hole craniostomy with an active subgaleal drain (BHC) and minicraniotomy with a passive subdural drain (MC). Methods We conducted a multicenter retrospective cohort study at two neurosurgical centers in Sweden which included patients with unilateral CSDHs that received surgical treatment with either BHC or MC. The primary outcomes in comparison of the techniques were 30-day mortality, recurrence rate, and complications according to the Landriel Ibañez grading system for complications. Results A total of 1003 patients were included in this study. The BHC subgroup included 560 patients, and the MC subgroup included 443 patients. A 30-day mortality when comparing BHC (2.3%) and MC (2.7%) was similar (p = 0.701). Comparing recurrence rate for BHC (8.9%) and MC (10.8%) showed no significant difference (p = 0.336). We found that medical complications were significantly more common in the MC group (p = 0.001). Surgical complications (type IIb) was also associated with the MC group (n = 10, p = 0.003). Out of the 10 patients with type IIb complications in the MC group, 8 had postoperative acute subdural hematomas. Conclusions BHC was comparable to MC concerning 30-day mortality rate and recurrence rates. We did, however, find that MC was significantly associated with medical complications and serious surgical postoperative complications.
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Affiliation(s)
- Shaian Zolfaghari
- Department of Neurosurgery, Institution of Clinical Sciences, Lund University, Lund, Sweden.
| | - Jiri Bartek
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Neuroscience and Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Isabelle Strom
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience and Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Felix Djärf
- Department of Neurosurgery, Institution of Clinical Sciences, Lund University, Lund, Sweden
| | - San-San Wong
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience and Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Nils Ståhl
- Department of Neurosurgery, Institution of Clinical Sciences, Lund University, Lund, Sweden
| | - Asgeir S Jakola
- Department of Neurosurgery, St. Olavs Hospital, Trondheim, Norway
- Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, University of Gothenburg, Sahlgrenska Academy, Gothenburg, Sweden
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Awake surgery in sitting position for chronic subdural hematoma. Acta Neurochir (Wien) 2021; 163:1857-1865. [PMID: 33464424 DOI: 10.1007/s00701-021-04704-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 01/04/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Chronic subdural hematoma (CSDH) is a common pathology in neurosurgery, especially in the elderly patients, and its incidence is likely to double in the next decade. Considering various features of CSDH and the procedure itself, a sitting position may retain the best characteristics of classic positioning, while offering additional comfort for both the patient and the surgeon. The aim of this study was to describe the technical aspects of this procedure in the sitting position, to evaluate safety and discuss the benefits and shortcomings of this modification. METHOD This study included a series of 55 patients surgically treated for CSDH in a sitting position at our department between December 2017 and September 2019, representing all the patients operated on during the study period by a single surgeon. Bilateral hematomas were present in 19 patients. Outcomes, during the 6-month follow-up period, were defined as good (CSDH and symptoms resolved) or poor (lethal outcome or reoccurrence). All complications were noted, with emphasis on pneumocephalus, and complications related to the sitting position: tension pneumocephalus, venous air embolism, and compression nerve injury. RESULTS Complications previously associated with the sitting position were not noted. The Glasgow Coma Scale and Markwalder Grading Scale scores improved significantly after the surgery (p < 0.001 and p = 0.018). Complications were noted in 17 patients (30.9%), and included 5 cerebrospinal fluid drainages, 3 hematoma reoccurrences, 2 wound infections, and 9 more single-occurring complications. The in-hospital mortality was 5.4% (3 out of 55 patients), while the overall mortality was 16.4% within the 6-month follow-up period. CONCLUSIONS In our series, even the severely ill patients tolerated the position well. No complications associated with the sitting position were noted. Future studies should confirm the safety of this position and evaluate the potential advantages for both the patient and the surgeon.
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Posti JP, Luoto TM, Rautava P, Kytö V. Mortality After Trauma Craniotomy Is Decreasing in Older Adults-A Nationwide Population-Based Study. World Neurosurg 2021; 152:e313-e320. [PMID: 34082165 DOI: 10.1016/j.wneu.2021.05.090] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 05/20/2021] [Accepted: 05/21/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE No evidence-based guidelines are available for operative neurosurgical treatment of older patients with traumatic brain injuries (TBIs), and no population-based results of current practice have been reported. The objective of the present study was to investigate the rates of trauma craniotomy operations and later mortality in older adults with TBI in Finland. METHODS Nationwide databases were searched for all admissions with a TBI diagnosis and after trauma craniotomy, and later deaths for persons aged ≥60 years from 2004 to 2018. RESULTS The study period included 2166 patients (64% men; mean age, 70.3 years) who had undergone TBI-related craniotomy. The incidence rate of operations decreased with a concomitant decrease in adjusted mortality (30-day mortality, P < 0.001; 1-year mortality, P < 0.001) and increase in mean patient age (R2 = 0.005; P < 0.001) during the study period. The cumulative mortality was 25% at 30 days and 38% at 1 year. The comorbidities increasing the hazard for 30-day mortality were diabetes, a history of malignancy, peripheral vascular disease, and a history of myocardial infarction. For 1-year mortality, the comorbidities were heart failure and a history of myocardial infarction. Evacuation of an epidural hematoma decreased the hazard for mortality. In contrast, evacuation of an intracerebral hematoma and decompressive craniectomy increased the risk at both 30 days and 1 year. CONCLUSIONS Among older adults in Finland, the rate of trauma craniotomy and later mortality has been decreasing although the mean age of operated patients has been increasing. This can be expected to be related to an improved understanding of geriatric TBIs and, consequently, improved selection of patients for targeted therapy.
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Affiliation(s)
- Jussi P Posti
- Neurocenter, Department of Neurosurgery and Turku Brain Injury Centre, Turku University Hospital and University of Turku, Turku, Finland.
| | - Teemu M Luoto
- Department of Neurosurgery, Tampere University Hospital and Tampere University, Tampere, Finland
| | - Päivi Rautava
- Clinical Research Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Ville Kytö
- Heart Centre and Center for Population Health Research, Turku University Hospital and University of Turku, Turku, Finland; Center for Population Health Research, Turku University Hospital and University of Turku, Turku, Finland; Research Center of Applied and Preventive Cardiovascular Medicine, University of Turku, Turku, Finland; Administative Center, Hospital District of Southwest Finland, Turku, Finland
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Chen JW, Xu JC, Malkasian D, Perez-Rosendahl MA, Tran DK. The Mini-Craniotomy for cSDH Revisited: New Perspectives. Front Neurol 2021; 12:660885. [PMID: 34025564 PMCID: PMC8134699 DOI: 10.3389/fneur.2021.660885] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 03/25/2021] [Indexed: 01/04/2023] Open
Abstract
Background: Chronic subdural hematomas (cSDH) are increasingly prevalent worldwide with the increased aging population and anticoagulant use. Different surgical, medical, and endovascular treatments have had varying success rates. Primary neurosurgical interventions include burr hole drainage of the cSDH and mini-craniotomies/craniotomies with or without fenestration of the inner membrane. A key assessment of the success or failure of cSDH treatments has been symptomatic recurrence rates which have historically ranged from 5 to 30%. Pre-operative prediction of the inner subdural membrane by CT scan was used to guide our decision to perform mini-craniotomies. Release of the inner membrane facilitates the expansion of the brain and likely improves glymphatic flow. Methods: Consecutive mini-craniotomies (N = 34) for cSDH evacuation performed by a single neurosurgeon at a quaternary academic medical center/Level I trauma center from July 2018-September 2020 were retrospectively reviewed. Patient characteristics [age, gender, presenting GCS, GOS, initial CTs noting the inner subdural membrane, midline shift (MLS), cSDH width, inner membrane fenestration, cSDH recurrence, post-operative seizures, infections, length of stay] were extracted from the EMR. Results: Twenty nine patients had mini-craniotomies as primary treatment of the cSDH. Mean age = 68.9 ± 19.7 years (range 22–102), mean pre-operative GCS = 14.5 ± 1.1, mean MLS = 6.75 ± 4.2 mm, and mean maximum thickness of cSDH = 17.7 ± 6.0 mm. Twenty four were unilateral, five bilateral, 34 total craniotomies were performed. Thirty three had inner membrane signs on pre-operative head CTs and an inner subdural membrane was fenestrated in all cases except for the one craniotomy that didn't show these characteristic CT findings. Mean operating time = 79.5 ± 26.0 min. Radiographic and clinical improvement occurred in all patients. Mean improvement in MLS = 3.85 ± 2.69. There were no symptomatic recurrences, re-operations, surgical site infections, or deaths during the 6 months of follow-up. One patient was treated for post-operative seizures with AEDs for 6 months. Conclusion: Pre-operative CT scans demonstrating inner subdural membranes may guide one to target the treatment to allow release of this tension band. Mini-craniotomy with careful fenestration of the inner membrane is very effective for this. Brain re-expansion and re-establishment of normal brain interstitial flow may be important in long term outcomes with cSDH and may be related to the recent interests in brain glymphatics and dural lymphatics.
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Affiliation(s)
- Jefferson W Chen
- Department of Neurological Surgery, University of California, Irvine, Orange, CA, United States
| | - Jordan C Xu
- Department of Neurological Surgery, University of California, Irvine, Orange, CA, United States
| | - Dennis Malkasian
- Department of Neurological Surgery, University of California, Irvine, Orange, CA, United States
| | - Mari A Perez-Rosendahl
- Neuropathology Division, Department of Pathology, University of California, Irvine, Orange, CA, United States
| | - Diem Kieu Tran
- Department of Neurological Surgery, University of California, Irvine, Orange, CA, United States
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Cannarsa GJ, Olexa J, Chryssikos T, Wessell AP, Sharma A, Miller TR, Jindal G, Aarabi B, Gandhi D. Stand-Alone Middle Meningeal Artery Embolization for Treatment of Giant Chronic Subdural Hematoma in Elderly Frail Patients: A Case Series. NEUROSURGERY OPEN 2021. [DOI: 10.1093/neuopn/okaa025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Merrill SA, Khan D, Richards AE, Kalani MA, Patel NP, Neal MT. Functional recovery following surgery for chronic subdural hematoma. Surg Neurol Int 2020; 11:450. [PMID: 33408935 PMCID: PMC7771503 DOI: 10.25259/sni_689_2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 11/21/2020] [Indexed: 01/08/2023] Open
Abstract
Background: Among the elderly, chronic subdural hematoma is a relatively common neurosurgical condition. Presenting symptoms range from headache and focal neurological deficits to seizure and coma depending on location and extent of brain compression. Functional recovery following surgery for chronic subdural hematoma is central to quality of life and ongoing health for elderly patients; however, there is a paucity of data regarding functional recovery in this population. Methods: In this study, the physical activity of patients who underwent surgical evacuation of chronic subdural hematoma was surveyed, as well as participation in physical therapy following surgery. In total, 38 patients completed the survey. Results: Of the 30 patients who exercised regularly before surgery, 28 (90.3%) returned to exercise within 1 year after surgery. Of 13 patients who reported playing hobby sports before surgery, 9 (69.2%) returned to those sports. 17/38 (44.7%) patients participated in physical therapy after surgery. 35/38 (92.1%) of patients reported that the surgery improved their quality of life. Conclusion: The majority of patients who underwent surgery for chronic subdural hematoma were able to return to exercise within 1 year. Participation in physical therapy was associated with return to exercise and sports. Further study is needed to determine which factors contribute to a return to baseline levels of physical activity following surgery for chronic subdural hematoma.
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Affiliation(s)
- Sarah A Merrill
- Department of Neurosurgery, Mayo Clinic Alix School of Medicine, Arizona, United States
| | - Daniel Khan
- Department of Neurosurgery, Mayo Clinic Alix School of Medicine, Arizona, United States
| | | | - Maziyar A Kalani
- Department of Neurosurgery, Mayo Clinic AZ, Phoenix, Arizona, United States
| | - Naresh P Patel
- Department of Neurosurgery, Mayo Clinic AZ, Phoenix, Arizona, United States
| | - Matthew T Neal
- Department of Neurosurgery, Mayo Clinic AZ, Phoenix, Arizona, United States
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Cofano F, Pesce A, Vercelli G, Mammi M, Massara A, Minardi M, Palmieri M, D'Andrea G, Fronda C, Lanotte MM, Tartara F, Zenga F, Frati A, Garbossa D. Risk of Recurrence of Chronic Subdural Hematomas After Surgery: A Multicenter Observational Cohort Study. Front Neurol 2020; 11:560269. [PMID: 33329304 PMCID: PMC7732444 DOI: 10.3389/fneur.2020.560269] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 10/14/2020] [Indexed: 01/31/2023] Open
Abstract
Background: Chronic Subdural Hematoma (CSDH) is a common condition in the elderly population. Recurrence rates after surgical evacuation range from 5 to 30%. Factors predicting recurrence remain debated and unclear. Objective: To identify factors associated with increased risk of recurrence. Methods: Cases of CSDHs that underwent surgical treatment between 2005 and 2018 in the Neurosurgery Units of two major Italian hospitals were reviewed. Data extracted from a prospectively maintained database included demographics, laterality, antithrombotic therapy, history of trauma, corticosteroid therapy, preoperative and postoperative symptoms, type of surgical intervention, use of surgical drain, and clinical outcomes. Results: A total of 1313 patients was analyzed. The overall recurrence rate was 10.1%. The risk of recurrence was not significantly different between patients with unilateral or bilateral CSDH (10.4 vs. 8.8%, p = 0.39). The risk of recurrence was higher in patients that underwent surgical procedure without postoperative drainage (16.1 vs. 5.4%, p < 0.01). No relationship was found between recurrence rates and therapy with antithrombotic drugs (p = 0.97). The risk of recurrence was increasingly higher considering craniostomy, craniectomy, and craniotomy (9.3, 11.3, and 18.9%, respectively, p = 0.013). Lower recurrence rates following Dexamethasone therapy were recorded (p = 0.013). Conclusion: No association was found between the risk of recurrence of CSDH after surgical evacuation and age, use of antithrombotic medication, or laterality. Burr-hole craniostomy was found to be associated with lower recurrence rates, when compared to other surgical procedures. Placement of surgical drain and Dexamethasone therapy were significantly associated with reduced risk of recurrence of CSDHs.
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Affiliation(s)
- Fabio Cofano
- Neurosurgery Unit, Department of Neuroscience "Rita Levi Montalcini", University of Turin, Turin, Italy
| | | | - Giovanni Vercelli
- Neurosurgery Unit, Department of Neuroscience "Rita Levi Montalcini", University of Turin, Turin, Italy
| | - Marco Mammi
- Neurosurgery Unit, Department of Neuroscience "Rita Levi Montalcini", University of Turin, Turin, Italy
| | - Armando Massara
- Neurosurgery Unit, Department of Neuroscience "Rita Levi Montalcini", University of Turin, Turin, Italy
| | - Massimiliano Minardi
- Neurosurgery Unit, Department of Neuroscience "Rita Levi Montalcini", University of Turin, Turin, Italy
| | - Mauro Palmieri
- Neurosurgery Unit, Department of Human Neuroscience, Sapienza University, Rome, Italy
| | | | - Chiara Fronda
- Stereotactic and Functional Neurosurgery Unit, Department of Neuroscience "Rita Levi Montalcini", University of Turin, Turin, Italy
| | - Michele Maria Lanotte
- Stereotactic and Functional Neurosurgery Unit, Department of Neuroscience "Rita Levi Montalcini", University of Turin, Turin, Italy
| | | | - Francesco Zenga
- Neurosurgery Unit, Department of Neuroscience "Rita Levi Montalcini", University of Turin, Turin, Italy
| | | | - Diego Garbossa
- Neurosurgery Unit, Department of Neuroscience "Rita Levi Montalcini", University of Turin, Turin, Italy
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