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Debs LH, Vale FL, Walker S, Toro D, Mansouri S, Macomson SD, Rahimi SY. Middle meningeal artery embolization following surgical evacuation of symptomatic chronic subdural hematoma improves outcomes, interim results of a prospective randomized trial. J Clin Neurosci 2024; 128:110783. [PMID: 39137714 DOI: 10.1016/j.jocn.2024.110783] [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: 06/14/2024] [Revised: 07/29/2024] [Accepted: 08/10/2024] [Indexed: 08/15/2024]
Abstract
BACKGROUND Outcomes after surgical treatment of chronic subdural hematoma (cSDH) remain undesirable in a significant proportion of patients. We aimed to show the role of middle meningeal artery (MMA) embolization and to demonstrate its benefits. METHODS Thirty-five patients with symptomatic cSDH were enrolled in a prospective randomized trial following evacuation surgery. Participants were randomized to embolization or control group (expectant management following surgical evacuation without embolization). Patients were followed throughout their hospitalization and outpatient follow-ups. The main goals of this planned interim analysis were to assess neurological outcome and resource utilization. RESULTS The groups were comparable in terms of sex, age and follow-up retention rates. Side(s) of intervention(s) and hematoma size were similar. There was no statistical difference in neurological examination improvement at discharge, but at follow-up, we observed a decline in neurologic exam in the control group (p = 0.03). Control group participants required more re-interventions (p = 0.02) and were followed in clinic and during related readmissions for longer (p = 0.02). The number of imaging studies obtained in relation to the disease management was higher in the control group (p = 0.01). CONCLUSIONS Our results suggest a beneficial role for the addition of MMA embolization to surgical intervention in the treatment of symptomatic chronic subdural hematoma. Neurological outcomes were significantly better in the embolization group. This contributed to less need for follow-up, re-interventions, and imaging studies.
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Affiliation(s)
- Luca H Debs
- Neurosurgery Department, Medical College of Georgia, Augusta, GA, USA.
| | - Fernando L Vale
- Neurosurgery Department, Medical College of Georgia, Augusta, GA, USA
| | - Samantha Walker
- Neurosurgery Department, Medical College of Georgia, Augusta, GA, USA
| | - Diana Toro
- Neurosurgery Department, Medical College of Georgia, Augusta, GA, USA
| | - Seena Mansouri
- Neurosurgery Department, Medical College of Georgia, Augusta, GA, USA
| | - Samuel D Macomson
- Neurosurgery Department, Medical College of Georgia, Augusta, GA, USA
| | - Scott Y Rahimi
- Neurosurgery Department, Medical College of Georgia, Augusta, GA, USA
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Arai M, Nakase K, Sasaki R, Nishimura F, Nakagawa I. Endoscope-Assisted Evacuation of an Acute Subdural Hematoma in an Elderly Patient With Refractory Nonconvulsive Status Epilepticus: An Illustrative Case. Cureus 2024; 16:e63817. [PMID: 39099992 PMCID: PMC11297714 DOI: 10.7759/cureus.63817] [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] [Accepted: 07/04/2024] [Indexed: 08/06/2024] Open
Abstract
Traumatic brain injuries lead to post-traumatic seizures (PTS), with acute subdural hematomas (ASDH) posing a particularly elevated risk. The development of refractory nonconvulsive status epilepticus (NCSE) in such cases, especially in older patients, requires immediate and effective management. This case report highlights the improvement of refractory NCSE in an elderly patient with ASDH through endoscope-assisted evacuation. An 88-year-old woman was hospitalized for dysarthria and right hemiparesis 3 days after a fall. Computed tomography (CT) revealed a left hemispheric ASDH, 9 mm thick, along with minor traumatic subarachnoid bleeding in the interpeduncular cistern. The initial treatment was conservative, including the administration of lacosamide at 100 mg/day. However, her consciousness deteriorated 4 days after admission, and she experienced convulsions in the right face and arm on day 5. Although the convulsions stopped after the administration of diazepam 10 mg IV and her consciousness temporarily improved, it worsened again on day 6, leading to a diagnosis of NCSE on an electroencephalogram (EEG). Despite aggressive pharmacological interventions with fosphenytoin (750 mg initially followed by 262 mg/day) and phenobarbital (625 mg/day), the patient's cognitive state and EEG findings did not improve. Consequently, on the 13th day, she underwent an endoscopic procedure to remove the SDH, which alleviated her symptoms and ended the seizures. This case demonstrates that even the absence of a significant mass effect from ASDH can trigger NCSE, underscoring the necessity for swift diagnosis and consideration of surgical options when conventional treatment fails. Endoscope-assisted evacuation is a safe and effective treatment option, particularly in older patients.
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Affiliation(s)
- Mika Arai
- Neurosurgery, Nara Medical University, Kashihara, JPN
| | - Kenta Nakase
- Neurosurgery, Nara Medical University, Kashihara, JPN
| | - Ryota Sasaki
- Neurosurgery, Nara Medical University, Kashihara, JPN
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Ryu HS, Kim SS, Hong WJ, Kim TS, Joo SP. Differences in gross appearance and histopathology of the outer membrane of the subdural hematoma envelope over time: A respective case series and literature review. Medicine (Baltimore) 2023; 102:e34257. [PMID: 37478245 PMCID: PMC10662858 DOI: 10.1097/md.0000000000034257] [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: 04/17/2023] [Accepted: 06/19/2023] [Indexed: 07/23/2023] Open
Abstract
RATIONALE Chronic subdural hematoma (CSDH) is a common disorder among elderly males. The most common theory of its cause is a minor brain injury resulting in the rupture of a bridging vein. The outer membrane of subdural hematoma (SDH) evolves like cutaneous wound healing with different phases. This report aims to use a surgical microscope and an electron microscope to show the pathophysiological differences in the temporal flow of the outer membrane of SDH. PATIENT CONCERNS This study retrospectively reviewed the cases of 6 patients who underwent craniotomy from 2016 to 2021 at the single center of Chonnam National University Hospital. DIAGNOSES These patients had a history of intracranial hematoma (ICH) at the surgical site on brain computed tomography (CT) before craniotomy. This study aimed to observe the morphological changes over time in the outer membrane of SDH and analyzed them through macroscopic and pathological findings. INTERVENTIONS AND OUTCOMES The outer membrane of SDH was confirmed in all six patients who underwent surgery, and macroscopic analysis was performed using an operating microscope. Three patients underwent pathological analysis through histological examination, and through this, the difference according to ICH occurrence and detection time was analyzed. LESSONS This study suggests that the outer membrane of SDH contains inflammatory and collagen cells in the early stages and thickens over time. This healing response is similar to cutaneous wound healing.
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Affiliation(s)
- Han Seung Ryu
- Department of Neurosurgery, Chonnam National University Hospital and Medical School, Gwangju, Republic of Korea
| | - Sung Sun Kim
- Department of Pathology, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Woo Jun Hong
- Department of Neurosurgery, Chonnam National University Hospital and Medical School, Gwangju, Republic of Korea
| | - Tae-Sun Kim
- Department of Neurosurgery, Chonnam National University Hospital and Medical School, Gwangju, Republic of Korea
| | - Sung-Pil Joo
- Department of Neurosurgery, Chonnam National University Hospital and Medical School, Gwangju, Republic of Korea
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Rodriguez B, Morgan I, Young T, Vlastos J, Williams T, Hrabarchuk EI, Tepper J, Baker T, Kellner CP, Bederson J, Rapoport BI. Surgical techniques for evacuation of chronic subdural hematoma: a mini-review. Front Neurol 2023; 14:1086645. [PMID: 37456631 PMCID: PMC10338715 DOI: 10.3389/fneur.2023.1086645] [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: 11/01/2022] [Accepted: 05/30/2023] [Indexed: 07/18/2023] Open
Abstract
Chronic subdural hematoma is one of the most common neurosurgical pathologies with over 160,000 cases in the United States and Europe each year. The current standard of care involves surgically evacuating the hematoma through a cranial opening, however, varied patient risk profiles, a significant recurrence rate, and increasing financial burden have sparked innovation in the field. This mini-review provides a brief overview of currently used evacuation techniques, including emerging adjuncts such as endoscopic assistance and middle meningeal artery embolization. This review synthesizes the body of available evidence on efficacy and risk profiles for each critical aspect of surgical technique in cSDH evacuation and provides insight into trends in the field and promising new technologies.
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Affiliation(s)
- Benjamin Rodriguez
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
- Icahn School of Medicine, New York, NY, United States
| | - Isabella Morgan
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
| | - Tirone Young
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
- Icahn School of Medicine, New York, NY, United States
| | - Joseph Vlastos
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
- Icahn School of Medicine, New York, NY, United States
| | - Tyree Williams
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
- Rensselaer Polytechnic Institute, Troy, NY, United States
| | - Eugene I. Hrabarchuk
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
- Icahn School of Medicine, New York, NY, United States
| | - Jaden Tepper
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
| | - Turner Baker
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
| | - Christopher P. Kellner
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
- Icahn School of Medicine, New York, NY, United States
| | - Joshua Bederson
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
- Icahn School of Medicine, New York, NY, United States
| | - Benjamin I. Rapoport
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
- Icahn School of Medicine, New York, NY, United States
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Plowman K, Lindner D, Valle-Giler E, Ashkin A, Bass J, Ruthman C. Subdural hematoma expansion in relation to measured mean and peak systolic blood pressure: A retrospective analysis. Front Neurol 2022; 13:1026471. [PMID: 36324382 PMCID: PMC9618657 DOI: 10.3389/fneur.2022.1026471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 09/21/2022] [Indexed: 11/13/2022] Open
Abstract
Objective Subdural hematomas (SDH) account for an estimated 5 to 25% of intracranial hemorrhages. Acute SDH occur secondary to rupture of the bridging veins leading to blood collecting within the dural space. Risk factors associated with SDH expansion are well documented, however, there are no established guidelines regarding blood pressure goals in the management of acute SDH. This study aims to retrospectively evaluate if uncontrolled blood pressure within the first 24 h of hospitalization in patients with acute SDH is linked to hematoma expansion as determined by serial CT imaging. Methods A single center, retrospective study looked at 1,083 patients with acute SDH, predominantly above age 65. Of these, 469 patients met the inclusion criteria. Blood pressure was measured during the first 24 h of admission along with PT, INR, platelets, blood alcohol level, anticoagulation use and antiplatelet use. Follow-up CT performed within the first 24 h was compared to the initial CT to determine the presence of hematoma expansion. Mean systolic blood pressure (SBP), peak SBP, discharge disposition, length of stay and in hospital mortality were evaluated. Results We found that patients with mean SBP <140 in the first 24 h of admission had a lower rate of hematoma expansion than those with SBP > 140. Patients with peak SBP > 200 had an increased frequency of hematoma expansion with the largest effect seen in patients with SBP > 220. Other risk factors did not contribute to hematoma expansion. Conclusions These results suggest that blood pressure is an important factor to consider when treating patients with SDH with medical management. Blood pressure management should be considered in addition to serial neurological exams, repeat radiological imaging, seizure prophylaxis and reversal of anticoagulation.
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Affiliation(s)
- Keegan Plowman
- Graduate Medical Education Internal Medicine Residency, NCH Healthcare System, Naples, FL, United States
- *Correspondence: Keegan Plowman
| | - David Lindner
- Division of Pulmonary Critical Care Medicine, NCH Healthcare System, Naples, FL, United States
| | - Edison Valle-Giler
- Division of Neurological Surgery, NCH Healthcare System, Naples, FL, United States
| | - Alex Ashkin
- Graduate Medical Education Internal Medicine Residency, NCH Healthcare System, Naples, FL, United States
| | - Jessica Bass
- Graduate Medical Education Internal Medicine Residency, NCH Healthcare System, Naples, FL, United States
| | - Carl Ruthman
- Division of Pulmonary Critical Care Medicine, NCH Healthcare System, Naples, FL, United States
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Robinson D, Pyle L, Foreman B, Ngwenya LB, Adeoye O, Woo D, Kreitzer N. Factors Associated with Early versus Delayed Expansion of Acute Subdural Hematomas Initially Managed Conservatively. J Neurotrauma 2020; 38:903-910. [PMID: 33107370 DOI: 10.1089/neu.2020.7192] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Acute subdural hematomas (ASDHs) are highly morbid and increasingly common. Hematoma expansion is a potentially fatal complication, and few studies have examined whether factors associated with hematoma expansion vary over time. To answer this, we performed a case-control study in a cohort of initially conservatively managed patients with ASDH. Two time periods were considered, early (<72 h from injury) and delayed (>72 h from injury). Cases were defined as patients who developed ASDH expansion in the appropriate period; controls were patients who had stable imaging. Associated factors were determined with logistic regression. We identified 68 cases and 237 controls in the early follow-up cohort. Early ASDH expansion was associated with coagulopathy (adjusted odds ratio [aOR] 2.3, 95 % CI: 1.2-4.5; p = 0.02), thicker ASDHs (aOR 1.1, 95% CI: 1.03-1.2; p = 0.006), additional intracranial lesions (aOR 3, 95% CI: 1.6-6.2; p = 0.002), no/minimal trauma history (aOR 0.4, 95% CI: 0.2-0.9; p = 0.03), and duration between injury and initial scan (aOR 0.9, 95% CI: 0.8-0.97; p = 0.04). In the delayed follow-up cohort, there were 41 cases and 126 controls. Delayed ASDH expansion was associated with older age (aOR 1.3 per 10 years, 95% CI: 1.1-1.6; p = 0.01), systolic blood pressure (SBP) >160 on hospital presentation (aOR 4.5, 95% CI: 1.8-11.3; p = 0.001), midline shift (aOR 1.5 per 1 mm, 95% CI: 1.3-1.9; p < 0.001), and convexity location (aOR 14.1, 95% CI: 2.6-265; p = 0.013). We conclude that early and delayed ASDH expansion are different processes with different associated factors, and that elevated SBP may be a modifiable risk factor of delayed expansion.
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Affiliation(s)
- David Robinson
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Logan Pyle
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio, USA.,Collaborative for Research on Acute Neurological Injuries, University of Cincinnati, Cincinnati, Ohio, USA
| | - Laura B Ngwenya
- Collaborative for Research on Acute Neurological Injuries, University of Cincinnati, Cincinnati, Ohio, USA.,Department of Neurosurgery, University of Cincinnati, Cincinnati, Ohio, USA
| | - Opeolu Adeoye
- Department of Neurosurgery, University of Cincinnati, Cincinnati, Ohio, USA.,Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Daniel Woo
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Natalie Kreitzer
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio, USA
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7
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AYDIN ÖZTÜRK P, ÖZTÜRK Ü, TAMAM Y. Kronik Subdural Hematom Sonrası Son Durum ve Bilişsel Fonksiyonların Değerlendirilmesi. DICLE MEDICAL JOURNAL 2020. [DOI: 10.5798/dicletip.800312] [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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Al Shaikh RH, Hasan TF, Becker TL, Ng Tucker LK, Meschia JF, Tawk RG, Ayala E, Freeman WD. Rapidly Resolving and Recurrent Contralateral Subdural Hematoma From Disseminated Intravascular Coagulation. J Stroke Cerebrovasc Dis 2020; 29:104872. [PMID: 32434727 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104872] [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: 01/20/2020] [Revised: 03/20/2020] [Accepted: 04/05/2020] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Acute, recurrent subdural hematoma (SDH) is a rare entity in the absence of trauma. Atraumatic SDH may be due to vascular disorders, coagulopathies, or intracranial hypotension. It is a rare complication of disseminated intravascular coagulation (DIC), with no prior reports in patients with intracranial metastatic colon cancer (MCC). Rapid resolution of the initial acute SDH with contralateral recurrence has not yet been reported in the literature. We present a case of rapidly resolving and recurrent, contralateral acute SDH from DIC secondary to MCC. CASE DESCRIPTION A 77-year-old woman with MCC presented with severe, acute onset headache. She progressed to unresponsiveness, dilated right pupil, and Glasgow Coma Scale (GCS) score of 4T. Initial computed tomography (CT) of the head demonstrated a right, 17-mm SDH with a right-to-left midline shift. Repeat CT head 8 hours later revealed resolution of the right SDH. She was extubated with notable clinical improvement. Laboratory examination showed international normalized ratio of 3.4, leukocytosis, and thrombocytopenia. The next morning, she became lethargic, GCS score of 3, with bilateral fixed pupils and dilated to 5-mm, and she was then reintubated. Repeat CT head demonstrated a new left SDH with bilateral uncal herniation. A small hyperdense focus in the left parietal region was suspicious for intraparenchymal hematoma versus a hemorrhagic metastatic focus. Shortly after, she was extubated due to do not resuscitate status, and she then passed away. CONCLUSIONS To our knowledge, this is the first case illustrating rapidly resolving and recurrent, contralateral acute SDH from DIC in a patient with MCC. Clinical recognition of this phenotypic pattern should raise the question of an underlying coagulopathy.
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Affiliation(s)
| | - Tasneem F Hasan
- Department of Neurology, Ochsner Louisiana State University Health Sciences Center, 1501 Kings Hwy, Shreveport 71103, Louisiana, United States.
| | - Tara L Becker
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, United States.
| | - Lauren K Ng Tucker
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida, United States.
| | - James F Meschia
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, United States.
| | - Rabih G Tawk
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, United States.
| | - Ernesto Ayala
- Department of Hematology and Medical Oncology, Mayo Clinic, Jacksonville, Florida, United States.
| | - William D Freeman
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, United States; Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida, United States; Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, United States.
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Management of Patients with Acute Subdural Hemorrhage During Treatment with Direct Oral Anticoagulants. Neurocrit Care 2020; 30:322-333. [PMID: 30382531 DOI: 10.1007/s12028-018-0635-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND Anticoagulation therapy is a major risk factor for unfavorable patient outcomes following (traumatic) intracranial hemorrhage. Direct oral anticoagulants (DOAC) are increasingly used for the prevention and treatment of thromboembolic diseases. Data on patients treated for acute subdural hemorrhage (SDH) during anticoagulation therapy with DOAC are limited. METHODS We analyzed the medical records of consecutive patients treated at our institution for acute SDH during anticoagulation therapy with DOAC or vitamin K antagonists (VKA) during a period of 30 months. Patient characteristics such as results of imaging and laboratory studies, treatment modalities and short-term patient outcomes were included. RESULTS A total of 128 patients with preadmission DOAC (n = 65) or VKA (n = 63) intake were compared. The overall 30-day mortality rate of this patient cohort was 27%, and it did not differ between patients with DOAC or VKA intake (26% vs. 27%; p = 1.000). Similarly, the rates of neurosurgical intervention (65%) and intracranial re-hemorrhage (18%) were comparable. Prothrombin complex concentrates were administered more frequently in patients with VKA intake than in patients with DOAC intake (90% vs. 58%; p < 0.0001). DOAC treatment in patients with acute SDH did not increase in-hospital and 30-day mortality rates compared to VKA treatment. CONCLUSIONS These findings support the favorable safety profile of DOAC in patients, even in the setting of intracranial hemorrhage. However, the availability of specific antidotes to DOAC may further improve the management of these patients.
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Won S, Dubinski D, Sautter L, Hattingen E, Seifert V, Rosenow F, Freiman T, Strzelczyk A, Konczalla J. Seizure and status epilepticus in chronic subdural hematoma. Acta Neurol Scand 2019; 140:194-203. [PMID: 31102548 DOI: 10.1111/ane.13131] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 05/05/2019] [Accepted: 05/14/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Acute symptomatic seizure (ASz) and status epilepticus (SE) are serious conditions associated with poor quality of life, with unfavorable psychosocial and functional outcome. Chronic subdural hematoma (cSDH) is a common neurosurgical disease related to those complications; therefore, we aimed to evaluate incidence, predictors of ASz/SE, and outcome in this cohort. METHODS We retrospectively analyzed patient diagnosed cSDH between 2010 and 2017. Beside their incidence of ASz/SE, patient characteristics, symptoms at admission, comorbidities, and all previously published relevant parameters were assessed. Recurrence rate and functional outcome were analyzed at hospital discharge and 90-day follow-up. RESULTS A total of 375 patients were included; incidence of ASz was 15.2% and of SE, 1.9%. In the univariate analysis, drainage insertion (P = 0.004; OR = 0.3) was a significant negative predictor for ASz/SE and multivariate analysis, including all significant parameters, designated GCS ≤13 at admission (P = 0.09; OR = 1.9), remote stroke (P = 0.009; OR = 2.9), and recurrence rate within 14 days (P = 0.001; OR = 3.3; with an incidence of 13%) as independent predictors for ASz/SE. Overall, patients with ASz/SE had significantly unfavorable outcome at discharge (54.7%; P < 0.001) and follow-up (39.5%; P < 0.001) with only slight improvement. Late seizures occurred in 3.8% within follow-up period. Any patient with SE had an unfavorable outcome at discharge without any improvement at follow-up having a mortality rate of 14.2%. CONCLUSION Independent predictors for ASz/SE are GCS ≤13 at admission, remote stroke, and recurrent hematoma in patients with cSDH, which is associated with worse functional outcome, particularly those with SE. Due to the higher rate of seizures than recurrence rate, a routine pre- and postoperative EEG besides CT is recommended.
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Affiliation(s)
- Sae‐Yeon Won
- Department of Neurosurgery University Hospital, Goethe‐University Frankfurt am Main Germany
| | - Daniel Dubinski
- Department of Neurosurgery University Hospital, Goethe‐University Frankfurt am Main Germany
| | - Lisa Sautter
- Department of Neurosurgery University Hospital, Goethe‐University Frankfurt am Main Germany
| | - Elke Hattingen
- Institute of Neuroradiology University Hospital, Goethe‐University Frankfurt am Main Germany
| | - Volker Seifert
- Department of Neurosurgery University Hospital, Goethe‐University Frankfurt am Main Germany
| | - Felix Rosenow
- Department of Neurology and Epilepsy Center Frankfurt Rhine‐Main University Hospital, Goethe‐University Frankfurt am Main Germany
| | - Thomas Freiman
- Department of Neurosurgery University Hospital, Goethe‐University Frankfurt am Main Germany
| | - Adam Strzelczyk
- Department of Neurology and Epilepsy Center Frankfurt Rhine‐Main University Hospital, Goethe‐University Frankfurt am Main Germany
| | - Juergen Konczalla
- Department of Neurosurgery University Hospital, Goethe‐University Frankfurt am Main Germany
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Bah AB, Souaré IS, Diawara S, Boubane D, Saran KO. [Surgical treatment of chronic subdural hematoma in Guinea: Analysis of 22 cases at the Kipe hospital of Conakry]. Neurochirurgie 2019; 65:83-88. [PMID: 30953620 DOI: 10.1016/j.neuchi.2019.03.005] [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: 04/16/2018] [Revised: 03/06/2019] [Accepted: 03/20/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE We report the results of surgical treatment of chronic subdural hematoma in the Kipe Hospital in Conakry, Guinea, for the period July 2012 to November 2015. MATERIAL AND METHOD Clinical, radiological and therapeutic data from 22 cases were collected retrospectively and analyzed, with a mean follow-up of 61.6 days. Univariate analysis screened for factors for neurological outcome on the Markwalder Grading Scale (MGS; 0=normal to 4=coma). RESULTS Male-female sex ratio was 2.6:1. Mean age at diagnosis was 71.09±8 years, with peak incidence of CSDH in the 60-79 age group. Traumatic brain injury was identified as causal in 40.9% of cases. Burrhole trepanation was used in 86.36% of cases, under local anesthesia in 76%, and with postoperative drainage in all cases. No recurrences were recorded. At follow-up, mean postoperative MGS was 0.59 (up from 3.08 preoperatively); 54.54% of patients had normal neurological examination (grade 0). Age 60-79 years, time to diagnosis>12 weeks and preoperative MGS≥3 had significant negative impact on outcome (respective P-values: 0.03, 0.001, 0.001). CONCLUSION Our data were similar to those of the literature, but with longer time to diagnosis and poorer initial clinical status, with negative impact on clinical progression.
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Affiliation(s)
- A B Bah
- Service de neurochirurgie, hôpital de l'amitié sino-guinéenne de Kipé, Conakry, Guinée; Service de chirurgie générale, CHU Ignace Deen, Kaloum, Conakry, Guinée.
| | - I S Souaré
- Service de neurochirurgie, hôpital de l'amitié sino-guinéenne de Kipé, Conakry, Guinée
| | - S Diawara
- Service de neurochirurgie, hôpital de l'amitié sino-guinéenne de Kipé, Conakry, Guinée; Service de neurochirurgie, CHU Donka, Donka, Conakry, Guinée
| | - D Boubane
- Service de neurochirurgie, hôpital de l'amitié sino-guinéenne de Kipé, Conakry, Guinée
| | - K O Saran
- Service de neurochirurgie, hôpital de l'amitié sino-guinéenne de Kipé, Conakry, Guinée
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12
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Risk Factors for Recurrent Hematoma After Surgery for Acute Traumatic Subdural Hematoma. World Neurosurg 2019; 124:e563-e571. [PMID: 30639489 DOI: 10.1016/j.wneu.2018.12.155] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 12/17/2018] [Accepted: 12/20/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The development of postcraniotomy hematoma (PCH) after surgery for acute traumatic subdural hematoma (aSDH) has been associated with an increased risk of a poor outcome. The risk factors contributing to PCH remain poorly understood. Our aim was to study the potential risk factors for PCH in a consecutive series of surgically evacuated patients with aSDH. METHODS A total of 132 patients with aSDH treated at Turku University Hospital (Turku, Finland) from 2008 to 2012 were enrolled in the present retrospective cohort study. The demographic, clinical, laboratory, and imaging data were collected from the medical records. A comprehensive analysis of the data using 6 different univariate methods, including machine learning and multivariate analyses, was conducted to identify the factors related to PCH. RESULTS The incidence of PCH after primary surgery for traumatic aSDH was 10.6%. The patients experiencing PCH were younger (P = 0.04). No difference was found in the use of anticoagulant or antiplatelet medication for the patients with and without PCH. Multivariate analyses identified alcohol inebriation at the time of injury (odds ratio [OR], 12.67; P = 0.041) and hypocapnia (OR, 26.09; P = 0.003) as independent risk factors for PCH. The patients with PCH had had hyponatremia (OR, 0.08; P = 0.018) less often, and their maximal systolic blood pressure was lower (OR, 0.94; P = 0.009). The area under the curve for the multivariate model was 0.96 (P = 0.049), with a Youden index of 0.88. CONCLUSIONS The results suggest that alcohol inebriation at the time of injury and hypocapnia during hospitalization are risk factors for the development of PCH.
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Incidence and Risk Factors of Intracranial Hemorrhage in Liver Transplant Recipients. Transplantation 2018; 102:448-453. [PMID: 29189631 DOI: 10.1097/tp.0000000000002005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Intracranial hemorrhage after liver transplantation is an infrequently reported complication but one which can have devastating consequences. METHODS We performed a retrospective cross-sectional analysis of all liver transplants performed between January 2010 and June 2015 at a single high-volume institution using a prospectively maintained electronic database and query of the electronic medical record. Cases of intracranial hemorrhage were adjudicated as either spontaneous intraparenchymal hemorrhage(IPH) or extra-axial hemorrhage (EAH). Patients with confirmed intracranial hemorrhage were compared with all other liver transplant recipients. Risk factors were identified by univariate analysis and logistic regression models for IPH and EAH. RESULTS Thirty-one (5.2%) of 595 liver transplant recipients developed an intracranial hemorrhage within 12 months of transplantation, 15 IPH and 16 EAH. The majority of intracranial hemorrhages were diagnosed within 1 month of transplantation. Eight (26%) intracranial hemorrhage patients died during hospitalization. Fourteen (45%) intracranial hemorrhage patients died within 1 year of transplantation and 1-year mortality was greater than in patients without intracranial hemorrhage (11.2%, P < 0.01). Female sex (adjusted odds ratio [OR], 3.291; 95% confidence interval [CI], 1.092-9.924; P = 0.034), higher pretransplant bilirubin (adjusted OR, 1.037; 95% CI, 1.006-1.070; P = 0.020), and greater increase in pretransplant to posttransplant systolic blood pressure (adjusted OR, 1.029; 95% CI, 1.006-1.052; P = 0.012) were associated with posttransplant IPH. Lower pretransplant serum fibrinogen level (adjusted OR, 0.988; 95% CI, 0.979-0.998; P = 0.017) was associated with posttransplant EAH. CONCLUSIONS Postoperative blood pressure control and pretransplant fibrinogen levels may be modifiable risk factors for preventing posttransplant intracranial hemorrhage.
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Kuhn EN, Erwood MS, Oster RA, Davis MC, Zeiger HE, Pittman BC, Fisher WS. Outcomes of Subdural Hematoma in the Elderly with a History of Minor or No Previous Trauma. World Neurosurg 2018; 119:e374-e382. [DOI: 10.1016/j.wneu.2018.07.168] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 07/17/2018] [Accepted: 07/19/2018] [Indexed: 10/28/2022]
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The profile of blunt traumatic infratentorial cranial bleed types. J Clin Neurosci 2018; 60:58-62. [PMID: 30342807 DOI: 10.1016/j.jocn.2018.10.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Accepted: 10/05/2018] [Indexed: 11/20/2022]
Abstract
Infratentorial traumatic intracranial bleeds (ICBs) are rare and the distribution of subtypes is unknown. To characterize this distribution the National Trauma Data Bank (NTDB) 2014 was queried for adults with single type infratentorial ICB, n = 1,821: subdural hemorrhage (SDH), subarachnoid hemorrhage (SAH), epidural hemorrhage (EDH), and intraparenchymal hemorrhage (IPH). Comparisons were made between the groups with statistical significance determined using chi squared and t-tests. SDH occurred in 29% of patients, mostly in elderly on anti-coagulants (13%) after a fall (77%), 42% of them underwent craniotomy, their mortality was the lowest (4%). SAH was the most common (56%) occurring mostly from traffic related injuries (27%). Furthermore, 9% of them had a severe head injury Glasgow Coma Scale ≤8 (GCS), but had the lowest Injury Severity Score (ISS, median 8) as well as a short hospital length of stay, 5.1 ± 6.2 days. These patients were most likely to be discharged to home (64%). They had the lowest mortality (4%). EDH was the least common ICB (5%), occurred in younger patients (median age 49 years), and it had the highest percentage of associated injuries (13%). EDH patients presented with the poorest neurological status (26% GCS ≤8, ISS median 25) and were operated on more than any other ICB type (55%). EDH was the highest mortality (9%) ICB type and had a low discharge to home rate (58%). IPH was uncommon (10%). Infratentorial bleeds types have different clinical courses, and outcomes. Understanding these differences can be useful in managing these patients.
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Affiliation(s)
- Vincent M Vacca
- Vincent M. VaccaJr, is adjunct faculty at Massachusetts College of Pharmacy and Health Sciences University in Boston, Mass., and Isabel Argento is a nurse in the Burn/Trauma/Surgical Intensive Care Unit at Brigham and Women's Hospital, also in Boston
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Influence of Postoperative Thrombosis Prophylaxis on the Recurrence of Chronic Subdural Hematoma After Burr-Hole Drainage. Crit Care Med 2018; 46:e26-e32. [DOI: 10.1097/ccm.0000000000002804] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Sahyouni R, Goshtasbi K, Mahmoodi A, Tran DK, Chen JW. Chronic Subdural Hematoma: A Historical and Clinical Perspective. World Neurosurg 2017; 108:948-953. [PMID: 28935548 DOI: 10.1016/j.wneu.2017.09.064] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 09/07/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND This review aims to highlight the clinical complexity of chronic subdural hematoma (cSDH) while presenting a brief historical discussion of cSDH. METHODS A thorough literature search of published English-language papers was performed in PubMed, Ovid, and Cochrane databases. RESULTS cSDH affects 1-5.3 per 100,000 individuals annually, with the incidence expected to rise as the U.S. population ages. The symptoms of cSDH are often nonspecific, with headaches being the most common complaint. Other symptoms include weakness, balance and gait problems, and memory problems. CONCLUSIONS A variety of clinical factors must be taken into account in the treatment of cSDH, and the multifaceted treatment paradigms continue to evolve.
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Affiliation(s)
- Ronald Sahyouni
- UC Irvine School of Medicine, Irvine, California, USA; UC Irvine Department of Biomedical Engineering, Irvine, California, USA
| | | | - Amin Mahmoodi
- UC Irvine Department of Neurological Surgery, Irvine, California, USA
| | - Diem K Tran
- UC Irvine Department of Neurological Surgery, Irvine, California, USA
| | - Jefferson W Chen
- UC Irvine Department of Neurological Surgery, Irvine, California, USA.
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Suarez JI, Kapinos G. Thromboembolism prevention after chronic subdural hematoma in the elderly. Neurology 2017; 88:1880-1881. [DOI: 10.1212/wnl.0000000000003923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Insular infarction in subdural hematoma: A case series and pathophysiologic review. J Clin Neurosci 2017; 39:4-8. [DOI: 10.1016/j.jocn.2017.02.054] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 02/13/2017] [Indexed: 11/22/2022]
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Won SY, Dubinski D, Herrmann E, Cuca C, Strzelczyk A, Seifert V, Konczalla J, Freiman TM. Epileptic Seizures in Patients Following Surgical Treatment of Acute Subdural Hematoma-Incidence, Risk Factors, Patient Outcome, and Development of New Scoring System for Prophylactic Antiepileptic Treatment (GATE-24 score). World Neurosurg 2017; 101:416-424. [PMID: 28213197 DOI: 10.1016/j.wneu.2017.02.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 02/06/2017] [Accepted: 02/07/2017] [Indexed: 11/18/2022]
Abstract
OBJECT Clinically evident or subclinical seizures are common manifestations in acute subdural hematoma (aSDH); however, there is a paucity of research investigating the relationship between seizures and aSDH. The purpose of this study is 2-fold: determine incidence and predictors of seizures and then establish a guideline in patients with aSDH to standardize the decision for prophylactic antiepileptic treatment. METHOD The author analyzed 139 patients with aSDH treated from 2007 until 2015. Baseline characteristics and clinical findings including Glasgow Coma Scale (GCS) at admission, 24 hours after operation, timing of operation, anticoagulation, and Glasgow Outcome Scale at hospital discharge and after 3 months were analyzed. Multivariate logistic regression analysis was performed to detect independent predictors of seizures, and a scoring system was developed. RESULTS Of 139 patients, overall incidence of seizures was 38%, preoperatively 16% and postoperatively 24%. Ninety percent of patients with preoperative seizures were seizure free after operation for 3 months. Independent predictors of seizures were GCS <9 (odds ratio [OR] 3.3), operation after 24 hours (OR 2.0), and anticoagulation (OR 2.2). Patients with seizures had a significantly higher rate of unfavorable outcome at hospital discharge (P = 0.001) and in 3-month follow-up (P = 0.002). Furthermore, a score system (GATE-24) was developed. In patients with GCS <14, anticoagulation, or surgical treatment 24 hours after onset, a prophylactic antiepileptic treatment is recommended. CONCLUSION Occurrence of seizures affected severity and outcomes after surgical treatment of aSDH. Therefore seizure prophylaxis should be considered in high-risk patients on the basis of the GATE-24 score to promote better clinical outcome.
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Affiliation(s)
- Sae-Yeon Won
- Department of Neurosurgery, University Hospital, Goethe-University, Frankfurt am Main, Germany.
| | - Daniel Dubinski
- Department of Neurosurgery, University Hospital, Goethe-University, Frankfurt am Main, Germany
| | - Eva Herrmann
- Department of Medicine, Institute of Biostatistics and Mathematical Modelling, University Hospital, Goethe-University, Frankfurt am Main, Germany
| | - Colleen Cuca
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital, Goethe-University, Frankfurt am Main, Germany
| | - Adam Strzelczyk
- Department of Neurology and Epilepsy Center Frankfurt Rhine-Main, University Hospital, Goethe-University, Frankfurt am Main, Germany
| | - Volker Seifert
- Department of Neurosurgery, University Hospital, Goethe-University, Frankfurt am Main, Germany
| | - Juergen Konczalla
- Department of Neurosurgery, University Hospital, Goethe-University, Frankfurt am Main, Germany
| | - Thomas M Freiman
- Department of Neurosurgery, University Hospital, Goethe-University, Frankfurt am Main, Germany
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Kim DI, Kim JH, Kang HI, Moon BG, Kim JS, Kim DR. Impact of Time Interval between Trauma Onset and Burr Hole Surgery on Recurrence of Late Subacute or Chronic Subdural Hematoma. J Korean Neurosurg Soc 2016; 59:498-504. [PMID: 27651869 PMCID: PMC5028611 DOI: 10.3340/jkns.2016.59.5.498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 06/14/2016] [Accepted: 07/20/2016] [Indexed: 11/27/2022] Open
Abstract
Objective Although subdural hematoma (SDH) is commonly treatable by burr hole surgery in the late subacute or chronic stage, there is no clear consensus regarding appropriate management and exact predictive factors for postoperative recurrence also remain unclear. The aim of this study was to evaluate risk factors associated with recurrence of SDH that requires burr hole surgery in the late subacute or chronic stage. We also identified the appropriate timing of surgery for reducing the recurrence. Methods We retrospectively reviewed 274 patients with SDH in the late subacute or chronic stage treated with burr hole surgery in our hospital between January 2007 and December 2014. Excluding patients with acute intracranial complications or unknown time of trauma onset left 216 patients included in the study. Results Of 216 patients with SDH in the late subacute or chronic stage, recurrence was observed in 36 patients (16.7%). The timing of the operation in patients with late subacute stage (15–28 days) resulted in a significant decrease in recurrence (RR, 0.33; 95% CI, 0.17–0.65; p=0.001) compared to chronic stage (>28 days). Otherwise, no significant risk factors were associated with recurrences including comorbidities and surgical details. Conclusion The results indicated that time from trauma onset to burr hole surgery may be important for decreasing the risk of recurrence. Therefore, unless patients can be treated conservatively without surgery, prompt surgical management is recommended in patients diagnosed as having late subacute or chronic subdural hematoma treatable by burr hole surgery, even when neurological deficits are unclear.
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Affiliation(s)
- Dae-In Kim
- Department of Neurosurgery, Eulji General Hospital, College of Medicine, Eulji University, Seoul, Korea
| | - Jae-Hoon Kim
- Department of Neurosurgery, Eulji General Hospital, College of Medicine, Eulji University, Seoul, Korea
| | - Hee-In Kang
- Department of Neurosurgery, Eulji General Hospital, College of Medicine, Eulji University, Seoul, Korea
| | - Byung-Gwan Moon
- Department of Neurosurgery, Eulji General Hospital, College of Medicine, Eulji University, Seoul, Korea
| | - Joo-Seung Kim
- Department of Neurosurgery, Eulji General Hospital, College of Medicine, Eulji University, Seoul, Korea
| | - Deok-Ryeong Kim
- Department of Neurosurgery, Eulji General Hospital, College of Medicine, Eulji University, Seoul, Korea
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