Management of Subdural Hematomas: Part II. Surgical Management of Subdural Hematomas

Fatal postoperative tension pneumocephalus after acute subdural hematoma evacuation: a case report

PURPOSE

Tension pneumocephalus (TP) represents a rare pathology characterized by constant accumulation of air in the intracranial space, being associated with increased risk of herniation, neurologic deterioration and death. Regarding neurosurgical trauma cases, TP is majorly encountered after chronic subdural hematoma evacuation. In this case report, we present a rare case of fatal postoperative TP encountered after craniotomy for evacuation of acute subdural hematoma (aSDH).

CASE PRESENTATION

An 83-year old gentleman was presented to the emergency department of our hospital with impaired level of consciousness. Initial examination revealed Glascow Coma Scale (GCS) 3/15, with pupils of 3 mm bilaterally and impaired pupillary light reflex. CT scan demonstrated a large left aSDH, with significant pressure phenomena and midline shift. Patient was subjected to an uneventful evacuation of hematoma via craniotomy and a closed subgaleal drain to gravity was placed. The following day and immediately after his transfer to the CT scanner, he presented with rapid neurologic deterioration with acute onset anisocoria and finally mydriasis with fixed and dilated pupils. Postoperative CT scan showed massive TP, and the patient was transferred to the operating room for urgent left decompressive craniectomy, with no intraoperative signs of entrapped air intracranially. Finally, he remained in severe clinical status, passing away on the eighth postoperative day.

CONCLUSION

TP represents a rare but severe neurosurgical emergency that may be also encountered after craniotomy in the acute trauma setting. Involved practitioners should be aware of this potentially fatal complication, so that early detection and proper management are conducted.

Perioperative management of adults with traumatic brain injury

Despite advances in management strategy, traumatic brain injury remains strongly associated with neurological impairment and mortality. Management of traumatic brain injury requires careful and targeted management of the physiological consequences which extend beyond the scope of the primary impact to the cranium. Here, we present a review of the principles of its acute management in adults. We outline the procedure which patients are assessed and the critical physiological variables which must be monitored to prevent further neurological damage. We describe current interventional strategies from the context of the underlying physiological mechanisms and recent clinical data and identify persisting challenges in traumatic brain injury management and potential avenues of future progress.

Awake transradial middle meningeal artery embolization and twist drill craniostomy for chronic subdural hematomas in the elderly: case series and technical note

BACKGROUND

Due to prohibitive perioperative risk factors, optimal treatment for chronic subdural hematomas (cSDH) in the elderly remains unclear. Minimally invasive techniques are a viable option and include bedside subdural evacuation port system (SEPS), as well as prevention of recurrence with middle meningeal artery (MMA) embolization. We present a case series of elderly patients undergoing combined transradial MMA embolization and bed-side craniostomy as primary treatment for cSDH.

METHODS

Patients 70 years and older from 2019 to 2020 that underwent single setting, awake transradial MMA embolization with concurrent SEPS placement under local anesthesia were included. Those with prior treatments, interventions performed under general anesthesia, or with less than 60-day follow-up were excluded. Descriptive analyses of baseline characteristics, radiologic parameters, comorbidities, and outcome measures were completed.

RESULTS

Twenty elderly patients (mean age of 81.0 years) with multiple comorbidities underwent 28 MMA embolization+SEPS procedures as primary treatment for cSDH. Mean cSDH thickness was 1.8cm±0.6 cm with 7.3±3.9 mm midline shift. All patients tolerated the procedure well. 1/20 (5.0%) patients died within 30 days of the procedure. A majority of patients were discharged to home (12/20; 60.0%). There was an average of 3.6-month follow-up and one patient (5.0%) developed recurrence in the follow-up period requiring further intervention.

CONCLUSIONS

In select elderly patients with high perioperative risk factors, primary treatment of cSDH using awake transradial MMA embolization+SEPS placement is a minimally invasive, feasible, and safe option. Further comparative studies are warranted to evaluate efficacy of the treatment.

Non-traumatic Acute Subdural Hematoma in a Patient With Scleroderma Complicated by Pulmonary Arterial Hypertension: A Case Report

Non-traumatic acute subdural hematoma (SDH) in patients with scleroderma is infrequently described in literature reviewing the neurologic disorders in scleroderma. We report a case of a patient with scleroderma complicated by severe pulmonary arterial hypertension (PAH), and a history of pulmonary embolism on warfarin who developed an SDH, requiring hemicraniectomy after initiating therapy with IV epoprostenol. The proposed mechanisms for SDH development and management strategy are discussed.

Spontaneous intracranial hypotension complicated by unilateral subdural hematoma, coma, and the rare Kernohan's notch phenomenon

Spontaneous intracranial hypotension (SIH) is a highly underdiagnosed condition with a wide range of manifestations. Although SIH has traditionally been viewed as having a benign disease course, recent evidence suggests otherwise. In this case report, we present a 71-year-old woman who was previously treated with a tapered dose of corticosteroids for an episode of SIH with behavioral manifestations. In this current report, we present her second episode which was complicated by a unilateral sub-acute subdural hematoma leading to loss of consciousness and coma. While the patient regained full consciousness and recovered considerably, she still suffers from ipsilateral hemiparesis as a result of Kernohan's notch phenomenon 2 years post-hospitalization. To the author's knowledge, this is the first case to involve persistent motor deficit after the resolution of SIH. We believe that surgical hematoma evacuation prior to addressing the cerebrospinal fluid leak may have contributed to aggregated downward displacement of the brain precipitating Kernohan's notch phenomenon.

Subdural Hematomas in Adults and Children

Subdural hematoma is a common entity encountered by the neurosurgeon. The disease has acute, subacute, and chronic forms. Management of the disease changes according to the etiology of the lesion, yet the main goals are, as with most neurosurgical interventions, decompression of neural tissue and restoration of perfusion. Due to various forms and causes of the disease such as trauma, anticoagulant/antiaggregant use, arterial rupture, oncologic hemorrhages, intracranial hypotension, and idiopathic hemorrhages, several approaches for management have been documented in the literature. Herewith, we present various up-to-date management options for the disease.

Valve-controlled chronic subdural hematoma drainage: A feasibility study

INTRODUCTION

Pneumocephalus after chronic subdural hematoma (CSDH) evacuation is a potential predictor of hematoma recurrence.

RESEARCH QUESTION

To study the feasibility and safety of a novel CSDH evacuation technique using a valve-controlled method to avoid pneumocephalus.

MATERIAL AND METHODS

In a retrospective case series, we evacuated CSDH using very low-pressure valve-controlled drains and recorded the neurological, radiological, and functional outcomes. Patients with primary CSDH, without previous neurosurgical intervention, and who did not receive antiplatelet or anticoagulant therapy the week prior to the index surgery, were included in the study. Exclusion criteria were the evacuation with other treatment techniques and incomplete data files. Patients were assessed according to the Bender grading system to record the neurological status. The hematoma volume was estimated using the formula for ellipsoid volumes.

RESULTS

Thirty-six patients with a mean age of 73 years (±9 years) fulfilled our eligibility criteria. Our technique was effective since it decreased the CSDH volume from 141 ​ml (IQR 97 ​ml) to 20.6 ​ml (IQR 26.59 ​ml; p ​< ​0.001) and improved the neurological status according to the Bender grading system from two (IQR 0.25) to 1 (IQR 0). However, pneumocephalus and hematoma recurrence occurred in one case each (2.8%). At six months, all patients returned to their previous status, except for two patients (5.6%) who died due to irrelevant pathologies.

CONCLUSIONS

Valve-controlled CSDH evacuation aiming to decrease the postoperative pneumocephalus and hematoma recurrence constitutes an effective and safe alternative. However, larger randomized controlled studies are required to establish its role in CSDH management.

Solve the post-operative subdural pneumatosis of chronic subdural hematoma: A novel active bone hole drainage system

Background

Post-operative subdural pneumatosis (PSP) is commonly encountered after the chronic subdural hematoma (CSDH) surgery which currently lacks effective methods to avoid the condition. This study invented an active bone hole drainage system to change the venting technique with the aim of comparing post-operative efficacy and prognosis to traditional drilling and drainage.

Methods

We conducted a randomized controlled trial between January 2020 and January 2021. A total of 86 patients undergoing surgery were assessed for eligibility, with 50 patients randomly assigned to the control group (received drilling and drainage) and 36 patients to the test group (received modified surgery). The 6-month follow-up was done after surgery. CSDH recurrence and post-operative hematoma re-increasement were the primary endpoints. The data from the two groups were compared and analyzed. This study was registered with the Chinese Clinical Trials Register (ChiCTR2200057158), and had ethics committee approval and patient consent.

Results

The incidence of PSP in the test group (0%, 0/30)was lower than the control group (93.88%, 46/49) (P &lt; 0.001). The brain non-expansion rates 3 days/weeks/months after surgery of the test group were 59.25 [49.62, 76.97], 52.10 [42.88, 72.45], and 29.45 [23.40, 36.95] respectively, which were lower than the control group which were 78.60 [69.50, 94.70], 73.10 [60.70, 87.40], and 61.70 [51.50, 78.30], respectively (P &lt; 0.001). The ADL scores a week/month/3/6 months after surgery of the test group were 100.00 [60.00, 100.00], 100.00 [85.00, 100.00], 100.00 [100.00, 100.00], 100.00 [100.00, 100.00], which were better than the control group's 60.00 [60.00, 80.00], 75.00 [60.00, 100.00], 100.00 [60.00, 100.00], 100.00 [60.00, 100.00] (P &lt; 0.05). The incidence of primary endpoints in the test group (10%, 3/30) was lower than the control group (34.69%, 17/49) (P &lt; 0.05).

Conclusions

Compared to drilling and drainage, the modified surgery with the active bone hole drainage system significantly reduced the incidence of PSP and primary endpoints and improved the post-operative efficacy and prognosis.

Clinical trial registration

Identifier: ChiCTR2200057158.

Effect of Twist-Drill Craniostomy With Hollow Screws for Evacuation of Chronic Subdural Hematoma: A Meta-Analysis

Objective

This study systematically reviews the clinical efficacy and safety of twist-drill craniostomy with hollow screws in chronic subdural hematoma treatment.

Methods

A computerized search of PubMed, Embase, Web of Science, Cochrane Library, World Health Organization International Trial Registry platform, CBM, CNKI, and Wanfang Database was performed to retrieve randomized controlled trials or case-control trials using twist-drill craniostomy (TDC) with hollow screws for the evacuation of chronic subdural hematoma from the date of databases' inception to July 2021. Two investigators independently screened the studies and extracted data in strict accordance with pre-established inclusion and exclusion criteria. RevMan 5.3 software or STATA was used for meta-analysis after evaluating the methodological quality of the included studies.

Results

A total of 4 randomized controlled trials and 16 case-control trials with a total of 2,536 cases were included. Results of the meta-analysis showed that the surgical success rate and postoperative recurrence rate of TDC with hollow screws were slightly higher compared to the burr hole craniostomy (BHC) group, but showed no statistical significance (RR = 1.03, P = 0.05; RR = 1.13, P = 0.50). However, subgroup analysis showed that the use of YL-1 needle had a higher success rate and lower recurrence rate (RR = 1.05, P = 0.02 < 0.05; RR = 0.584, P = 0.002), and TDC with hollow screws had a lower incidence rate of postoperative complications and postoperative acute intracranial hemorrhage compared with BHC, also revealing an overall shorter hospital stay (RR = 0.57, P = 0.0002 < 0.05; RR = 0.584, P = 0.027 < 0.05; WMD = −3.752, P < 0.001). However, the postoperative mortality rate was practically the same between the two groups (OR = 1.01, P = 0.95 > 0.05).

Conclusion

Twist-drill craniostomy with hollow screws is not inferior or superior to BHC in efficacy, and this strategy is safer and minimally invasive, which is reflected in a lower incidence of acute intracranial hemorrhage, overall complication rate, and length of hospital stay.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier: CRD42021270835.

Neuro-Ophthalmologic Monitoring in the Management of Increased Intracranial Pressure From Leaking Arachnoid Cysts

BACKGROUND

Intracranial arachnoid cysts are common incidental imaging findings. They may rarely rupture, leading to the development of subdural hygromas and high intracranial pressure (ICP). Neurosurgical intervention has been advocated in the past, but recent evidence indicates that most cases resolve spontaneously. The role of neuro-ophthalmologic monitoring in identifying the few cases that have persisting vision-threatening papilledema that justifies intervention has not been emphasized.

METHODS

Retrospective review of 4 cases of leaking arachnoid cysts drawn from the files of the University of Michigan Medical Center (Michigan Medicine) between 2007 and 2018.

RESULTS

In 1 case, surgery was avoidable as papilledema resolved over time despite lingering imaging features of mass effect. In 3 cases, papilledema persisted with the threat of permanent vision loss, prompting neurosurgical intervention. In one of those cases, the fluid collection was thinly but extensively spread across both hemispheres without brain shift; yet, papilledema was pronounced. Emergent evacuation led to rapid resolution of papilledema and encephalopathy, but with residual optic nerve damage.

CONCLUSIONS

Because constitutional symptoms and even imaging are not always reliable indicators of high ICP in leaking arachnoid cysts, neuro-ophthalmologic monitoring of papilledema is valuable in identifying the cases when neurosurgical intervention is necessary.

Awake surgery in sitting position for chronic subdural hematoma

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.

Minimally Invasive Endoscopy for Acute Subdural Hematomas: A Report of 3 Cases

BACKGROUND

Acute subdural hematomas (aSDHs) occur in approximately 10% to 20% of all closed head injury and represent a significant cause of morbidity and mortality in traumatic brain injury patients. Conventional craniotomy is an invasive intervention with the potential for excess blood loss and prolonged postoperative recovery time.

OBJECTIVE

To evaluate the outcomes of minimally invasive endoscopy for evacuation of aSDHs in a pilot feasibility study.

METHODS

We retrospectively reviewed the records of consecutive patients with aSDHs who underwent surgical treatment at our institution with minimally invasive endoscopy using the Apollo/Artemis Neuro Evacuation Device (Penumbra, Alameda, California) between April 2015 and July 2018.

RESULTS

The study cohort comprised three patients. The Glasgow Coma Scale on admission was 15 for all 3 patients, median preoperative hematoma volume was 49.5 cm3 (range 44-67.8 cm3), median postoperative degree of hematoma evacuation was 88% (range 84%-89%), and median modified Rankin Scale at discharge was 1 (range 0-3).

CONCLUSION

Endoscopic evacuation of aSDHs can be a safe and effective alternative to craniotomy in appropriately selected patients. Further studies are needed to refine the selection criteria for endoscopic aSDH evacuation and evaluate its long-term outcomes.

Middle meningeal artery embolization with subdural evacuating port system for primary management of chronic subdural hematomas

Optimal treatment for chronic subdural hematomas remains controversial and perioperative risks and comorbidities may affect management strategies. Minimally invasive procedures are emerging as alternatives to the standard operative treatments. We evaluate our experience with middle meningeal artery (MMA) embolization combined with Subdural Evacuating Port System (SEPS) placement as a first-line treatment for patients with cSDH. A single institution retrospective review was performed of all patients undergoing intervention. Patients were stratified by treatment with MMA embolization and SEPS placement, MMA embolization and surgery, SEPS placement only, and surgery only for cSDH from 2017 to 2020, and cohorts were compared against each other. Patients treated with MMA/SEPS were more likely to be older, be on anticoagulation, have significant comorbidities, have shorter length of stay, and less likely to have symptomatic recurrence compared to SEPS only cohort. Thus, MMA/SEPS appears to be a safe and equally effective minimally invasive treatment for cSDH patients with significant comorbidities who are poor surgical candidates.

Blunt and Penetrating Severe Traumatic Brain Injury

Severe traumatic brain injury is a common problem. Current practices focus on the importance of early resuscitation, transfer to high-volume centers, and provider expertise across multiple specialties. In the emergency department, patients should receive urgent intracranial imaging and consideration for tranexamic acid. Close observation in the intensive care unit environment helps identify problems, such as seizure, intracranial pressure crisis, and injury progression. In addition to traditional neurologic examination, patients benefit from use of intracranial monitors. Monitors gather physiologic data on intracranial and cerebral perfusion pressures to help guide therapy. Brain tissue oxygenation monitoring and cerebromicrodialysis show promise in studies.

Surgical Procedure in the Treatment of Organized Chronic Subdural Hematoma: A Single-Center Experience

BACKGROUND

Organized chronic subdural hematoma (CSDH) is a special type of CSDH. However, the optimal surgical procedure has not been established. We present our experience here to discuss the surgical procedure in treatment of organized CSDH.

METHODS

 Thirty-three patients with organized CSDH were admitted between January 1, 2008 and January 1, 2018. Age, gender, clinical symptoms, imaging data, type of surgical procedure, Barthel index (BI), and postoperative complications were collected and retrospectively analyzed. The BI was assessed both pre and postoperatively (1 week and 1 month after surgery).

RESULTS

 Overall, 14 patients underwent large craniotomy and 19 patients underwent small craniotomy. No significant differences in gender, age, initial clinical symptoms, and preoperative BI were found between the groups (p > 0.05). Among the 14 patients who underwent large craniotomy, 2 patients developed epilepsy after the operation, while 1 patient had postoperative aphasia. None of the patients had recurrence in 6 months postoperatively. Among the 19 patients who underwent small craniotomy, 1 patient developed an acute subdural hematoma and 1 patient developed aphasia. No obvious complications were found in the remaining 18 patients and none of the 19 patients had recurrence in 6 months postoperatively. BI scores of the small craniotomy group were significantly better than those of the large craniotomy group at 1 week postoperatively (p < 0.05). However, there was no significant difference in the 1-month results (p > 0.05).

CONCLUSION

 According to our single-center experience, a small craniotomy for treating organized CSDH can be considered as an alternative to a larger craniotomy.

Prediction Models for Recurrence of Chronic Subdural Hematoma in Patients Underwent Twist-Drill Craniostomy Combined With Urokinase Instillation

The recurrence of chronic subdural hematoma (CSDH) is high post-treatment. In this study, we aimed to construct individualized models for prediction of the postoperative recurrence of CSDH in patients underwent twist-drill craniostomy combined with urokinase (UK) instillation. In total, 183 patients with CSDH were retrospectively enrolled. In summary, 21 candidate factors were retrieved from past medical records. The least absolute shrinkage and selection operator regression was adopted to reduce the high dimensionality of data. Four predictors: preoperative hematoma volume, encephalatrophy, brain re-expansion, and UK instillation frequency were filtered from the 21 candidate factors using the least absolute shrinkage and selection operator method. Binary logistic regression model was employed to establish preoperative and postoperative prediction models. The preoperative model included preoperative hematoma volume and encephalatrophy whereas the postoperative model included brain re-expansion and UK instillation frequency. The predictive performance of the nomograms was evaluated by the receiver operating characteristic curve and calibration chart. Area under curve of the preoperative and postoperative models were 0.755 (95% confidence interval: 0.690-0.889) and 0.782 (95% confidence interval: 0.720-0.936), respectively, indicating good discrimination ability. The calibration results showed good fitting between the predicted probability and the actual probability. Finally, a decision curve analysis revealed excellent clinical performance of the proposed nomograms. Functionally, the preoperative model was used to identify high-risk patients with CSDH and application of UK, while the postoperative model was applied to guide physician-patients communication during follow-up. These 2 prediction models provide a basis for further clinical and experimental studies.

Benefits of the Subdural Evacuating Port System (SEPS) Procedure Over Traditional Craniotomy for Subdural Hematoma Evacuation

Background

There remains no consensus on the optimal primary intervention for subdural hematoma (SDH). Although historically favored, craniotomy carries substantial morbidity and incurs significant costs. Contrastingly, the subdural evacuating port system (SEPS) is a minimally invasive bedside procedure. We assessed the benefits of SEPS over traditional craniotomy for SDH evacuation.

Methods

A single-center retrospective cohort study of SDH patients receiving craniotomy or SEPS between 2012 and 2017 was performed. Information regarding demographics, medical history, presentation, surgical outcomes, cost, and complications was collected. Pre- and postoperative hematoma volumes were calculated using 3D image segmentation using Vitrea software. Multivariate regression models were employed to assess the influence of intervention choice.

Results

Of 107 patients, 68 underwent craniotomy and 39 underwent SEPS. There were no differences in age, sex, blood thinner use, platelet count, INR, hematoma lateralization, age, volume, or midline shift at presentation between intervention groups. Although there was no difference in percent residual hematoma volume 24-hour postintervention (44.1% vs 45.1%, P = .894), SEPS was associated with lower hospitalization costs ($108 391 vs $166 318, *P = .002), shorter length of stay (4.0 vs 5.8 days, *P = .0002), and fewer postoperative seizures (2.6% vs 17.7%, *P = .048). Reoperation rate was higher after SEPS overall (33.3% vs 13.2%, *P = .048) but comparable to craniotomy in chronic SDH (12.50% vs 7.69%, P = 1.000).

Conclusion

In this retrospective cohort, SEPS was noninferior to craniotomy at reducing SDH hematoma volume. The SEPS procedure was also associated with decreased length of stay hospitalization costs, and postoperative seizures and demonstrated a comparable recurrence rate to craniotomy for chronic SDH in particular.

Single Versus Double Burr Hole Craniostomy in Surgical Treatment of Chronic Subdural Hematoma: A Meta-Analysis

BACKGROUND

Chronic subdural hematoma (cSDH) is one of the most common illnesses seen in neurosurgery departments worldwide. For surgical treatment, some neurosurgeons prefer single burr hole craniostomy (SBHC), whereas others prefer double burr hole craniostomy (DBHC). We performed a meta-analysis to investigate whether DBHC is associated with increased risks of recurrence, complications and mortality compared with SBHC in patients with cSDH.

METHODS

Retrospective observational trial or randomized controlled trial (RCT) studies concerning burr hole craniostomy to treat cSDH were systematically identified through a search of electronic databases: PubMed, Web of Science, Embase, and Cochrane. Inclusion and exclusion criteria were defined for the eligible studies. The random fixed-effects model was used when heterogeneity was indicated; otherwise, a fixed-effects model was adopted.

RESULTS

This meta-analysis included 12 studies, 3 of which were RCTs. Our findings can be summarized as follows. First, SBHC did not increase the risk of recurrence compared with DBHC in patients with cSDH (odds ratio [OR], 1.28; 95% confidence interval [CI], 0.92-1.78; P =0.07). Second, DBHC was not associated with an increased complication rate compared with SBHC in patients with cSDH (OR, 0.74; 95% CI, 0.20-2.76; P = 0.11). Third, DBHC did not increase mortality compared with SBHC in patients with cSDH (OR, 1.38; 95% CI, 0.55-3.46; P = 0.58).

CONCLUSIONS

This meta-analysis demonstrates that there are no significant differences in recurrence rate, complication rate, and morbidity between SBHC and DBHC in the treatment of patients with cSDH.