Chronic Subdural Hematoma (cSDH): A review of the current state of the art

Comparison of Postoperative Seizures Between Burr-Hole Evacuation and Craniotomy in Patients With Nonacute Subdural Hematomas: A Bi-Institutional Propensity Score-Matched Analysis

BACKGROUND AND OBJECTIVES

Postoperative seizures are a common complication after surgical drainage of nonacute chronic subdural hematomas (SDHs). The literature increasingly supports the use of prophylactic antiepileptic drugs for craniotomy, a procedure that is often associated with larger collections and worse clinical status at admission. This study aimed to compare the incidence of postoperative seizures in patients treated with burr-hole drainage and those treated with craniotomy through propensity score matching (PSM).

METHODS

A retrospective cohort analysis was conducted on patients with surgical drainage of nonacute SDHs (burr-holes and craniotomies) between January 2017 to December 2021 at 2 academic institutions in the United States. PSM was performed by controlling for age, subdural thickness, subacute component, and preoperative Glasgow Coma Scale. Seizure rates and accompanying abnormalities on electroencephalographic tracing were evaluated postmatching.

RESULTS

A total of 467 patients with 510 nonacute SDHs underwent 474 procedures, with 242 burr-hole evacuations (51.0%) and 232 craniotomies (49.0%). PSM resulted in 62 matched pairs. After matching, univariate analysis revealed that burr-hole evacuations exhibited lower rates of seizures (1.6% vs 11.3%; P = .03) and abnormal electroencephalographic findings (0.0% vs 4.8%; P = .03) compared with craniotomies. No significant differences were observed in postoperative Glasgow Coma Scale (P = .77) and length of hospital stay (P = .61).

CONCLUSION

Burr-hole evacuation demonstrated significantly lower seizure rates than craniotomy using a propensity score-matched analysis controlling for significant variables.

Active Versus Passive Drainage Systems for Subdural Hematomas: A Systematic Review and Meta-Analysis

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.

Assessment of Surgical Treatment and Outcome of Chronic Subdural Hematoma at University of Gondar Comprehensive Specialized Hospital, a one Year Prospective Study

OBJECTIVE

Chronic subdural hematomas (CSDHs) are a relatively common condition defined as an abnormal collection of blood and its break down products in the subdural space, usually accompanied by a history of preceding mild head trauma. Surgical management remains the mainstay of treatment. The objective of this study was to assess the surgical treatment outcome of patients operated on for CSDH at University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia. This comprehensive novel study serves as a benchmark for assessing therapeutic outcomes among patients with CSDH in the context of Ethiopia.

METHODS

Institution-based prospective observational study was conducted among patients operated on for symptomatic CSDH at University of Gondar Comprehensive Specialized Hospital from January 1, 2023, to December 31, 2023 G C.

RESULT

A total of 107 patients (70 males (65.4%) and 37 females (34.6%) with a male to female ration of 1.9:1 and mean age of 62.4 and a standard deviation of 13.7 (range from 23 to 92) were studied. Fifyt-one (47.7%) of the patients had a history of antecedent trauma. In terms of clinical symptoms, 86 (80.4%) patients had weakness as the chief complaint, followed by headache in 81 (75.7%). Among complications, recurrence is the most common, which was seen in 16 (15%) patients, followed by altered mental status (confusion, delirium) in 18 (16.8%) patients. The mean duration of the hospital stay was 6 days, with a standard deviation of 4 days. The majority of the patients had a good recovery with the resumption of normal life: 92 (86%), 10 (9.3%) patients had moderate disability, were disabled but independent, 2 (1.8%) patients had severe disability, were dependent on daily support, and 3 (2.8%) patients died.

CONCLUSION

CSDHs are a relatively common condition characterized by an abnormal collection of blood. Antecedent trauma is the usual risk factor. Complication can happen following surgical intervention; however, patients with CSDH generally have a good prognosis.

Comparative efficacy of dexamethasone versus surgery for chronic subdural hematoma: A systematic review and meta-analysis

OBJECTIVE

To assess the comparative efficacy of dexamethasone (DXM) as monotherapy in comparison to surgery among the patients of chronic subdural hematoma (CSDH).

METHODS

We searched MEDLINE, PUBMED, EMBASE, and Cochrane Central Register of Controlled Trials databases from inception till September 2023. Data was extracted, pooled and analyzed from all the studies that assessed the comparative efficacy of DXM as monotherapy in contrast with surgery as the primary treatment of CSDH.

RESULTS

A total of 6 studies involving 704 patients were included in our meta-analysis. Comparison of surgery to DXM revealed there was no statistically significant difference between the two groups regarding mortality [RR=1.09; 95% CI; 0.52-2.28 P = 0.83]. However, a significantly higher incidence of secondary surgical intervention was observed in the DXM group [RR 4.24; 95% CI; 2.06-8.71 P < 0.0001]. No significant difference in performance was observed in terms of poor postoperative outcomes within hospital stay [RR 1.12, 95% CI, 0.40-3.19 P=0.83] and at 6 months [RR 0.92, 95%CI, 0.40-2.13 P=0.85].

CONCLUSION

DXM had a significantly higher incidence of secondary surgical intervention. However, there was no difference regarding mortality and other safety outcomes between surgery and DXM for the patients with CSDH. Observational studies showed that DXM was associated with a lower risk of poor postoperative outcomes within hospital stay and had shorter duration of hospital stay, but the recurrence rate was lower in the surgery group.

How artificial intelligence can provide information about subdural hematoma: Assessment of readability, reliability, and quality of ChatGPT, BARD, and perplexity responses

Subdural hematoma is defined as blood collection in the subdural space between the dura mater and arachnoid. Subdural hematoma is a condition that neurosurgeons frequently encounter and has acute, subacute and chronic forms. The incidence in adults is reported to be 1.72-20.60/100.000 people annually. Our study aimed to evaluate the quality, reliability and readability of the answers to questions asked to ChatGPT, Bard, and perplexity about "Subdural Hematoma." In this observational and cross-sectional study, we asked ChatGPT, Bard, and perplexity to provide the 100 most frequently asked questions about "Subdural Hematoma" separately. Responses from both chatbots were analyzed separately for readability, quality, reliability and adequacy. When the median readability scores of ChatGPT, Bard, and perplexity answers were compared with the sixth-grade reading level, a statistically significant difference was observed in all formulas (P < .001). All 3 chatbot responses were found to be difficult to read. Bard responses were more readable than ChatGPT's (P < .001) and perplexity's (P < .001) responses for all scores evaluated. Although there were differences between the results of the evaluated calculators, perplexity's answers were determined to be more readable than ChatGPT's answers (P < .05). Bard answers were determined to have the best GQS scores (P < .001). Perplexity responses had the best Journal of American Medical Association and modified DISCERN scores (P < .001). ChatGPT, Bard, and perplexity's current capabilities are inadequate in terms of quality and readability of "Subdural Hematoma" related text content. The readability standard for patient education materials as determined by the American Medical Association, National Institutes of Health, and the United States Department of Health and Human Services is at or below grade 6. The readability levels of the responses of artificial intelligence applications such as ChatGPT, Bard, and perplexity are significantly higher than the recommended 6th grade level.

Correlating Age and Hematoma Volume with Extent of Midline Shift in Acute Subdural Hematoma Patients: Validation of an Artificial Intelligence Tool for Volumetric Analysis

OBJECTIVE

Decision for intervention in acute subdural hematoma patients is based on a combination of clinical and radiographic factors. Age has been suggested as a factor to be strongly considered when interpreting midline shift (MLS) and hematoma volume data for assessing critical clinical severity during operative intervention decisions for acute subdural hematoma patients. The objective of this study was to demonstrate the use of an automated volumetric analysis tool to measure hematoma volume and MLS and quantify their relationship with age.

METHODS

A total of 1789 acute subdural hematoma patients were analyzed using qER-Quant software (Qure.ai, Mumbai, India) for MLS and hematoma volume measurements. Univariable and multivariable regressions analyzed association between MLS, hematoma volume, age, and MLS:hematoma volume ratio.

RESULTS

In comparison to young patients (≤ 70 years), old patients (>70 years) had significantly higher average hematoma volume (old: 62.2 mL vs. young 46.8 mL, P < 0.0001), lower average MLS (old: 6.6 mm vs. young: 7.4 mm, P = 0.025), and lower average MLS:hematoma volume ratio (old: 0.11 mm/mL vs. young 0.15 mm/mL, P < 0.0001). Young patients had an average of 1.5 mm greater MLS for a given hematoma volume in comparison to old patients. With increasing age, the ratio between MLS and hematoma volume significantly decreases (P = 0.0002).

CONCLUSIONS

Commercially available, automated, artificial intelligence (AI)-based tools may be used for obtaining quantitative radiographic measurement data in patients with acute subdural hematoma. Our quantitative results are consistent with the qualitative relationship previously established between age, hematoma volume, and MLS, which supports the validity of using AI-based tools for acute subdural hematoma volume estimation.

Synthetic minority over-sampling technique-enhanced machine learning models for predicting recurrence of postoperative chronic subdural hematoma

Objective

Chronic subdural hematoma (CSDH) is a neurological condition with high recurrence rates, primarily observed in the elderly population. Although several risk factors have been identified, predicting CSDH recurrence remains a challenge. Given the potential of machine learning (ML) to extract meaningful insights from complex data sets, our study aims to develop and validate ML models capable of accurately predicting postoperative CSDH recurrence.

Methods

Data from 447 CSDH patients treated with consecutive burr-hole irrigations at Wenzhou Medical University's First Affiliated Hospital (December 2014-April 2019) were studied. 312 patients formed the development cohort, while 135 comprised the test cohort. The Least Absolute Shrinkage and Selection Operator (LASSO) method was employed to select crucial features associated with recurrence. Eight machine learning algorithms were used to construct prediction models for hematoma recurrence, using demographic, laboratory, and radiological features. The Border-line Synthetic Minority Over-sampling Technique (SMOTE) was applied to address data imbalance, and Shapley Additive Explanation (SHAP) analysis was utilized to improve model visualization and interpretability. Model performance was assessed using metrics such as AUROC, sensitivity, specificity, F1 score, calibration plots, and decision curve analysis (DCA).

Results

Our optimized ML models exhibited prediction accuracies ranging from 61.0% to 86.2% for hematoma recurrence in the validation set. Notably, the Random Forest (RF) model surpassed other algorithms, achieving an accuracy of 86.2%. SHAP analysis confirmed these results, highlighting key clinical predictors for CSDH recurrence risk, including age, alanine aminotransferase level, fibrinogen level, thrombin time, and maximum hematoma diameter. The RF model yielded an accuracy of 92.6% with an AUC value of 0.834 in the test dataset.

Conclusion

Our findings underscore the efficacy of machine learning algorithms, notably the integration of the RF model with SMOTE, in forecasting the recurrence of postoperative chronic subdural hematoma. Leveraging the RF model, we devised an online calculator that may serve as a pivotal instrument in tailoring therapeutic strategies and implementing timely preventive interventions for high-risk patients.

A nomogram for predicting the possibility of effusion deterioration in patients with traumatic subdural effusion

BACKGROUND

Traumatic subdural effusion (TSDE) may increase progressively or evolve into chronic subdural hematoma. These events, defined as deterioration of the effusion, often require close observation or even surgical treatment. The aim of our study was to develop and validate a nomogram for predicting the possibility of an effusion deteriorating in patients with TSDE based on the available clinical characteristics.

METHODS

Clinical data from 78 patients with TSDE were retrospectively analyzed. All patients were admitted from January 2019 to May 2022. Logistic regression was applied to the data to screen for independent predictors of effusion deterioration within six months; then, a predictive nomogram model was established in R language. The consistency, predictive accuracy and clinical utility of the model were evaluated with the C-index, calibration plots, ROC curves and decision curve analysis (DCA). Furthermore, we performed internal validation using a bootstrap approach to assess the effectiveness of the model.

RESULTS

Time of effusion after trauma, maximum thickness of the effusion, CT value of the effusion as well as the use of atorvastatin were identified as predictors in the nomogram. The predictive model was well calibrated and demonstrated good discrimination (C-index: 0.893). The AUC of the model was 0.893 (95% CI: 0.824-0.962), and the modified C-index (0.865) indicated excellent performance in the internal validation. In addition, DCA revealed that the nomogram had clinical value.

CONCLUSIONS

This predictive model can effectively assess the risk of effusion deterioration in TSDE patients within six months and identify high-risk patients early.

Charlson Comorbidity Index and Frailty as Predictors of Resolution Following Middle Meningeal Artery Embolization for Chronic Subdural Hematoma

BACKGROUND

Research on variables associated with chronic subdural hematoma (cSDH) resolution following middle meningeal artery embolization (MMAE) is limited. This study investigated the clinical utility of age-adjusted Charlson Comorbidity Index (ACCI) and modified 5-item Frailty Index (mFI - 5) for predicting cSDH resolution following MMAE.

METHODS

We identified patients who underwent MMAE at our institution between January 2018 and December 2022, with at least 20 days of follow-up and one radiographic follow-up study. Patient demographics, characteristics, and outcomes were collected. Complete resolution was defined as absence of subdural collections on CT-scan at last follow-up. Nonage adjusted CCI (CCI), ACCI, and mFI - 5 scores were calculated. Univariate and multivariable logistic regression analyzed the relationship between cSDH resolution and variables. A receiver operating characteristic (ROC) curve established the utility of ACCI and mFI - 5 in predicting hematoma resolution.

RESULTS

The study included 85 MMAE procedures. In univariate analysis, patients without resolution were older, had higher CCI, higher ACCI, higher mFI - 5, and were more likely to have diabetes mellitus. In multivarible analysis, CCI (OR: 0.66, 95% CI: 0.48, 0.91) was independently associated with resolution controlling for age and antithrombotic resumption. The area under the ROC (AUROC) curve was 0.75 (95% CI: 0.65-0.85) for ACCI and 0.64 (95% CI: 0.52-0.76) for mFI - 5. The optimal cutoffs for predicting resolution were ACCI ≥5 (sensitivity = 0.63, specificity = 0.77), and mFI - 5 > 0 (sensitivity = 0.84, specificity = 0.43).

CONCLUSIONS

ACCI and mFI - 5 moderately predict MMAE resolution and may aid in medical decision-making.

Simple coiling of middle meningeal artery embolization for chronic subdural hematoma: An inverse probability of treatment weighting matched cohort study

BACKGROUND

Middle meningeal artery embolization (MMAE) for chronic subdural hematoma (CSDH) has gained much attention in recent years. However, unintended embolization may occur when employing liquid embolic agents or particles. We present our clinical experience in simple coiling of MMAE to manage CSDH.

METHODS

Patients underwent either surgical evacuation or MMAE with simple coiling for CSDH were reviewed. Clinical and radiographic outcomes were assessed at admission, 1-month, and 6-month intervals. Two treatment groups were matched with inverse probability of treatment weighting.

RESULTS

One hundred twelve patients were included, with 27 patients in MMAE group and 87 patients in surgery group. In MMAE group, significant reductions were observed in hematoma width (admission vs. 1-month, 2.04 [1.44-2.60] cm vs. 0.62 [0.37-0.95] cm, p < 0.001). The adjusted odds ratio (aOR) of surgical rescue rate (0.77 95%CI 0.13-4.47, p = 0.77), hematoma reduction (>50%) (0.21 95%CI 0.04-1.07, p = 0.06), and midline shift improvement rate (3.22, 95%CI 0.84-12.4, p = 0.09) had no substantial disparities between two groups at 1-month follow-up. In addition, no significant difference was noted between two groups in terms of hematoma reduction (>50%) at 6-month follow-up (aOR 1.09 95%CI 0.32-3.70, p = 0.89). No procedure-related complications were found in MMA embolization group.

CONCLUSION

Simple coiling for MMA had comparable outcomes with surgical evacuation for CSDH. Our findings suggest that simple coiling can be an alternative choice for liquid agents or particles in MMA embolization for CSDH with acceptable safety.

Case report: Concurrent low-volume subdural hematoma and ipsilateral ischemic stroke presenting as capsular warning syndrome: a complex case with anticoagulation dilemma and dual pathology

Background

The simultaneous emergence of low-volume subdural hematoma and ipsilateral ischemic stroke in an atrial fibrillation patient who is under anticoagulation therapy is a rare and intricate clinical case. This report accentuates the diagnostic and treatment complexities associated with these consecutive neurological conditions.

Case presentation

An 83 years-old male patient initially presented with acute dyspnea, raising the suspicion of pulmonary embolism. After exclusion of pulmonary embolism through CT angiography, the patient experienced a sudden onset of left-sided hemiparesis without prior history of head trauma but with chronic intake of apixaban due to atrial fibrillation. Subsequent cranial CT tomography revealed a small right parietal subdural hematoma. After reversal of the anticoagulation therapy, surgical evacuation of the subdural hematoma was successfully performed. However, in the postoperative period, the patient developed new neurological symptoms that could not be explained by the reduced size of the subdural hematoma on a follow-up CT scan. Cranial MRI revealed the coexistence of acute ischemic stroke in the right corona radiata. The recent surgical procedure precluded guideline-recommended stroke treatment.

Discussion

This case underscores the complexities of diagnosing and treating concomitant small volume subdural hematoma and ischemic stroke, especially if the latter occurs in the corona radiata resulting in fluctuating symptoms known as "capsular warning syndrome." Reversal and secondary discontinuation of anticoagulant therapy for surgical intervention highlight the inherent risk of thrombotic events in anticoagulated patients. The development of tailored treatment strategies requires a multidisciplinary approach, and further research and guidelines are required in similar complex scenarios.

Conclusion

The presence of both a small subdural hematoma and an ipsilateral ischemic stroke presenting as capsular warning syndrome in an anticoagulated patient highlights the intricacy of their care. This case calls for a comprehensive and collaborative strategy to address complicated clinical scenarios.

Patient with a history of Glanzmann thrombasthenia presented with chronic subdural hematoma: a case report study

Glanzmann thrombasthenia (GT) is a rare platelet disorder characterized by qualitative/quantitative deficiencies of the platelets' fibrinogen receptor, glycoprotein (GP) IIb/IIIa complex, resulting in impaired platelet aggregation and increased bleeding time. Most cases are hereditary with an autosomal recessive pattern of inheritance, but acquired GT also occurs. We report the surgical management of symptomatic chronic subdural hematoma (CSDH), a rare condition in young individuals, in a 37-year-old man who had GT and a history of mild head trauma approximately one month before admission. Despite hematologic consultation, normal bleeding time and clotting time, and platelet transfusion before surgery, massive hemorrhage during surgery, epidural hematoma, and anisocoria in the ICU occurred that led to craniectomy. This report highlights that CSDH management in patients with GT requires close monitoring of these patients as well as collaboration between neurosurgeons, intensive care physicians, hematologists, and anesthesiologists.

Clinical Characteristics and Prognoses of Chronic Subdural Hematoma Patients with and without Head Trauma: A Retrospective Comparative Study

OBJECTIVE

Head trauma is considered as the main cause of chronic subdural hematoma (CSDH). However, many patients develop CSDH with no identified cause. Herein, we conduct a comparative study to investigate the differences in clinical characteristics and surgical outcomes of CSDH patients with and without a history of head trauma.

METHODS

We retrospectively reviewed CSDH patients who underwent surgical treatment in our hospital between January 2013 and December 2021. Patients were categorized into a with head trauma (WHT) group and a without head trauma (WOHT) group for comparative analysis.

RESULTS

A total of 219 patients were included, 119 (54.3%) cases in the WHT group and 100 (45.7%) cases in the WOHT group. More cancer patients were found in the WOHT group than in the WHT group (P = 0.045). Both at discharge and 6-month follow-up, patients in the WOHT group achieved better clinical outcomes than the WHT group cases (P = 0.025 and 0.034, respectively). Furthermore, ordered multiclass logistic regression analyses indicated that a history of head trauma (odds ratio 2.151, 95% confidence interval 1.052-4.386; P = 0.036) was a risk factor significantly related to the unfavorable outcomes at 6-month follow-ups of CSDH. However, we did not find significant differences between the 2 groups in clinical manifestations, radiological characteristics, postoperative complications, mortality, and recurrence rates.

CONCLUSIONS

CSDH patients with a history of head trauma may be more susceptible to unfavorable outcomes; thus, they should be carefully evaluated and given more attention during hospitalization and after discharge.

Efficacy of intraoperative irrigation with artificial cerebrospinal fluid in chronic subdural hematoma surgery: study protocol for a multicenter randomized controlled trial

BACKGROUND

The surgical techniques for treatment of chronic subdural hematoma (CSDH), a common neurosurgical condition, have been discussed in a lot of clinical literature. However, the recurrence proportion after CSDH surgery remains high, ranging from 10 to 20%. The standard surgical procedure for CSDH involves a craniostomy to evacuate the hematoma, but irrigating the hematoma cavity during the procedure is debatable. The authors hypothesized that the choice of irrigation fluid might be a key factor affecting the outcomes of surgery. This multicenter randomized controlled trial aims to investigate whether intraoperative irrigation using artificial cerebrospinal fluid (ACF) followed by the placement of a subdural drain would yield superior results compared to the placement of a subdural drain alone for CSDH.

METHODS

The study will be conducted across 19 neurosurgical departments in Japan. The 1186 eligible patients will be randomly allocated to two groups: irrigation using ACF or not. In either group, a subdural drain is to be placed for at least 12 h postoperatively. Similar to what was done in previous studies, we set the proportion of patients that meet the criteria for ipsilateral reoperation at 7% in the irrigation group and 12% in the non-irrigation group. The primary endpoint is the proportion of patients who meet the criteria for ipsilateral reoperation within 6 months of surgery (clinical worsening of symptoms and increased hematoma on imaging compared with the postoperative state). The secondary endpoints are the proportion of reoperations within 6 months, the proportion being stratified by preoperative hematoma architecture by computed tomography (CT) scan, neurological symptoms, patient condition, mortality at 6 months, complications associated with surgery, length of hospital stay from surgery to discharge, and time of the surgical procedure.

DISCUSSION

We present the study protocol for a multicenter randomized controlled trial to investigate our hypothesis that intraoperative irrigation with ACF reduces the recurrence proportion after the removal of chronic subdural hematomas compared with no irrigation.

TRIAL REGISTRATION

ClinicalTrials.gov jRCT1041220124. Registered on January 13, 2023.

Middle Meningeal Artery Embolization versus Surgery in Patients with Chronic Subdural Hematoma-No More Fence Sitting?

BACKGROUND

Endovascular treatment of patients with chronic subdural hematoma using middle meningeal artery (MMA) embolization could become an alternative to surgical hematoma evacuation. The aim of the study was to compare methods and identify parameters to help determine the correct treatment modality.

METHODS

We retrospectively reviewed 142 cases conducted internally; 78 were treated surgically and 64 were treated using MMA embolization. We analyzed the treatment failure rate and complications, and using a binary logistic regression model, we identified treatment failure risk factors.

RESULTS

We found a comparable treatment failure rate of 23.1% for the surgery group and 21.9% for the MMA embolization group. However, in the MMA embolization group, 11 cases showed treatment failure due to early neurological worsening with a need for concomitant surgery. We also found a recurrence of hematoma in 15.4% of cases in the surgery group and 6.3% of cases in the MMA embolization group.

CONCLUSION

Both modalities have their advantages; however, correct identification is crucial for treatment success. According to our findings, hematomas with a maximal width of <18 mm, a midline shift of <5 mm, and no acute or subacute (hyperdense) hematoma could be treated with MMA embolization. Hematomas with a maximal width of >18 mm, a midline shift of >5 mm, and no membranous segmentation could have better outcomes after surgical treatment.

Delayed Recognition, Surgical Dilemmas, and Complications: A Case Report of Acute-on-Chronic Subdural Hematoma With Ischemic Stroke

Acute-on-chronic subdural hematoma (SDH) is a new hemorrhage on a preexisting hematoma in the space between the dura mater and the arachnoid layer. Although chronic SDH is common, acute-on-chronic SDH is not. Herein, we present a case of a 70-year-old male with ischemic heart disease, diabetes mellitus, and hypertension who presented with worsening headaches for the past three days, associated with gait imbalance and dizziness. The patient was vitally stable on examination with a Glasgow Coma Scale/Score (GCS) of 15/15; his pupils were reactive bilaterally; and his neurological examination was unremarkable. Non-contrast computed tomography (CT) of the head yielded acute and chronic SDH. The patient was initially managed by embolization of the middle meningeal artery (EMMA), but one day later he developed a stroke. Hence, thrombectomy and burr hole craniotomy were performed to manage the stroke and evacuate the chronic subdural hematoma (CSDH). This paper presents this case as uncommon acute on chronic SDH presented with headache and vertigo, treated with embolization and with complications of stroke and pulmonary embolism.

Safety of middle meningeal artery embolization for treatment of subdural hematoma: A nationwide propensity score matched analysis

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.

The interdural hematoma: A subtype of convexity subdural/dural hematoma with specific radioanatomical characteristics

Background

Rare cases of biconvex hematomas splitting the convexity dura mater were reported and denominated interdural hematoma (IDH). Due to their rarity, little is known about their radiological characteristics, and in most cases, their invasive management with craniotomy and dural membrane excision is unnecessary.

Case Description

We report here a case of single burr-hole endoscopic evacuation of an IDH and its complete resolution after the 6-month follow-up imaging. The literature review reveals 11 reported cases of IDH. Most of them are male and the mean age is 65 years (range 51-90). Most of the reported IDHs were misdiagnosed as epidural hematoma or meningioma, and therefore, they have been managed invasively through craniotomy with dural excision. Diagnosis of the interdural nature was confirmed macroscopically during surgery in all cases and histology was reported for 6 cases. Image analysis found a double dural beak sign and biconvex shape on coronal planes, subarachnoid space enlargement at the collection extremities, and irregular thick inner wall as common radiological aspects of the IDH.

Conclusion

IDH is a rarely reported and often misdiagnosed dural hematoma subtype. Its invasive treatment through craniotomy is likely related to its unknown radiological characteristics. We review and raise awareness about potentially unique radiological anatomy that could avoid unnecessary invasive treatment. Moreover, we report the first case of endoscopically evacuated IDH with long-term follow-up imaging showing complete resolution.

Comparison of surgical strategies in patients with chronic subdural haematoma: a protocol for a network meta-analysis

INTRODUCTION

Chronic subdural haematoma (CSDH) is one of the most common neurosurgical emergencies, especially in the elderly population. Surgery is the mainstay of treatment for CSDH. Some studies have suggested that some specific surgical strategies can have potential benefits for patients with CSDH; however, the best surgical method is still controversial. For a better understanding of surgical treatment for these patients, it is necessary to conduct a network meta-analysis to comprehensively compare the effects of medical treatment and different surgical methods.

METHODS AND ANALYSIS

This protocol has been reported following the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols. Related studies published up to April 2023 will be searched in the following databases: PubMed, Embase, Scopus, Web of Science, the Cochrane Library, China National Knowledge Infrastructure, VIP and Wanfang. Randomised controlled trials and non-randomised prospective studies comparing at least two different interventions for patients with CSDH will be included. Quality assessment will be conducted using Cochrane Collaboration's tool or the Newcastle-Ottawa Scale based on study design. The primary outcome will be the recurrence rates, and the secondary outcome will be the functional outcome at the end of follow-up. Pairwise and network meta-analyses will be conducted using STATA V.14 (StataCorp, College Station, Texas, USA). Mean ranks and the surface under the cumulative ranking curve will be used to evaluate each intervention. Statistical inconsistency assessment, subgroup analysis, sensitivity analysis and publication bias assessment will be performed.

ETHICS AND DISSEMINATION

Ethics approval is not necessary because this study will be based on publications. The results of this study will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42022376829.

Comparison of different surgical techniques for chronic subdural hematoma: a network meta-analysis

Background

Chronic subdural hematoma (CSDH) is a neurosurgical condition with high prevalence. Many surgical approaches are recommended for treating CSDH, but there needs to be a consensus on the optimal technique. This network meta-analysis (NMA) compared the efficacy and safety of different surgical treatments for CSDH.

Methods

Electronic databases, including PubMed, Embase, and the Cochrane Library, were searched for relevant studies up to February 2023. An NMA was performed to compare the outcomes of patients with CSDH treated by single-hole or double-hole craniotomy (SBHC and DBHC, respectively), twist-drill craniotomy (TDC), mini-craniotomy, and craniotomy. The NMA protocol was registered at INPLASY (registration no. 202320114).

Results

The NMA included 38 studies with 7,337 patients. For efficacy outcomes, DBHC showed the highest surface under the cumulative ranking area (SUCRA) values for recurrence (96.3%) and reoperation (87.4%) rates. DBHC differed significantly from mini-craniotomy in recurrence rate (odds ratio [OR] = 0.58, 95% confidence interval [CI]: 0.35, 0.97) and from SBHC (OR = 0.48, 95% CI: 0.25, 0.91) and TDC (OR = 0.40, 95% CI: 0.20, 0.82) in reoperation rate. For operative time, TDC was superior to SBHC (mean difference [MD] = -2.32, 95% CI: -3.78 to -0.86), DBHC (MD = -3.61, 95% CI: -5.55, -1.67), and mini-craniotomy (MD = -3.39, 95% CI: -5.70, -1.08). Patients treated by TDC had a shorter hospital stay than those treated by SBHC (MD = -0.82, 95% CI: -1.51, -0.12). For safety outcomes, there were no significant differences between groups in mortality and complication rates; however, mini-craniotomy (79.8%) and TDC (78.1%) had the highest SUCRAs.

Conclusion

DBHC may be the most effective surgical treatment for CSDH based on the low recurrence and reoperation rates, although all examined techniques were relatively safe.

Systematic review registration

https://inplasy.com/inplasy-2023-2-0114/.

Clinical Characteristics and Surgical Outcomes of Super-Elderly Patients with Chronic Subdural Hematoma

OBJECTIVE

Surgical intervention for chronic subdural hematoma (CSDH) in the extremely aged population remains a difficult challenge. This study aims to investigate the clinical characteristics and surgical outcomes after twist drill craniotomy (TDC) of CSDH in super-elderly (≥80 years) patients.

METHODS

A retrospective analysis of super-elderly patients with CSDH who underwent TDC treatment in our hospital between January 2013 and December 2021 was performed. Their clinical characteristics and surgical outcomes were compared with those of relatively younger patients (60-79 years). Factors that may affect functional outcomes were also investigated.

RESULTS

Fifty-nine super-elderly patients and 133 patients aged 60-79 years were included. The preoperative hematoma volume of the super-elderly patients was significantly larger than that of the 60-79 years group, whereas fewer super-elderly patients had headaches compared with the relatively younger counterparts. After surgical treatment using the TDC procedure, the incidence of complication and the hematoma recurrence rate were similar between the 2 groups. Moreover, according to the Markwalder score of the follow-up at 6 months after operation, the prognosis of the super-elderly group was not poorer than that of the patients of 60-79 years (P = 0.662). Preoperative dysfunction of coagulation (odds ratio, 28.421; 95% confidence interval, 1.185-681.677; P = 0.039) was an independent risk factor significantly related to unfavorable outcomes of super-elderly patients with CSDH.

CONCLUSIONS

Advanced age per se does not seem to be a contraindication for the operative intervention of CSDH. Surgical treatment using the TDC procedure can still provide considerable benefits for super-elderly patients with CSDH.

Middle Meningeal Artery Embolization in the Management of Chronic Subdural Hematoma: a Comprehensive Review of Current Literature

PURPOSE OF REVIEW

Chronic subdural hematoma (cSDH) is a common intracranial hemorrhagic disorder with a high incidence rate among the elderly. While small, asymptomatic cSDH may resolve spontaneously, surgical intervention has been the treatment of choice for larger, symptomatic cases. Surgical evacuation of cSDH may be associated with high rates of recurrence, and even asymptomatic cSDH cases tend to progress. Over the last few years, middle meningeal artery (MMA) embolization has proven to be a safe non-invasive treatment of choice with favorable outcomes and a low recurrence rate. The ensuing paper discusses current treatment modalities for cSDH and reviews existing literature on the anatomy of MMA and its embolization as a treatment option for cSDH.

RECENT FINDINGS

Recent studies show that traumatic head injury leading to subdural hemorrhage can induce neovascularization that may initiate a cycle of recurrent subdural hematoma. Distal branches of MMA supply blood to the dural layers. Several studies have revealed that embolization of the MMA can stop the neovascularization process and blood flow. In addition, patients who underwent MMA embolization had a significantly quicker brain re-expansion and lower recurrence rate. Although the management of cSDH is still very much a dilemma, recent research findings bring MMA embolization to light as a promising treatment alternative and adjunctive therapy.

Subdural Lesions Linking Additional Intracranial Spaces and Chronic Subdural Hematomas: A Narrative Review with Mutual Correlation and Possible Mechanisms behind High Recurrence

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.

Middle meningeal artery embolization for treatment of chronic subdural hematoma

BACKGROUND

Chronic subdural hematoma (cSDH) is caused by rupture of bridging intracranial veins located in the subdural space. Predominantly, cSDH is a disease of older adults and other predisposing risk factors include minor head trauma, cerebral atrophy, antiplatelet and anticoagulation therapies, arterial hypertension, cerebrovascular atherosclerosis, diabetes mellitus, cerebrospinal fluid loss, and excessive alcohol consumption. The incidence of cSDH is rising worldwide due to an aging population and the increased use of anticoagulant or antiplatelet medications. Clinical manifestations are varied, with altered mental status and focal neurologic deficits among the most common.

METHODOLOGICAL INNOVATIONS

Treatment strategies depend on the symptomatology and extent of hematoma. In general, conservative treatment is sought for patients who are asymptomatic or have only mild symptoms, whereas symptomatic patients are often treated surgically. However, the recurrence rate of cSDH may be as high as 30%. In recent years, middle meningeal artery embolization has emerged as a complementary option to surgery aimed at decreasing the recurrence rate after excision as well as an alternative therapeutic approach to surgical therapy in certain circumstances.

CONCLUSION

Embolization of the middle meningeal artery appears to be a promising treatment for patients with cSDH, both before and after surgical excision.

Clinical Outcomes of 3D-Printed Bioresorbable Scaffolds for Bone Tissue Engineering-A Pilot Study on 126 Patients for Burrhole Covers in Subdural Hematoma

Burrhole craniostomy is commonly performed for subdural hematoma (SDH) evacuation, but residual scalp depressions are often cosmetically suboptimal for patients. OsteoplugTM, a bioresorbable polycaprolactone burrhole cover, was introduced by the National University Hospital, Singapore, in 2006 to cover these defects, allowing osseous integration and vascular ingrowth. However, the cosmetic and safety outcomes of OsteoplugTM-C-the latest (2017) iteration, with a chamfered hole for subdural drains-remain unexplored. Data were collected from a single institution from April 2017 to March 2021. Patient-reported aesthetic outcomes (Aesthetic Numeric Analog (ANA)) and quality of life (EQ-5D-3L including Visual Analog Scale (VAS)) were assessed via telephone interviews. Clinical outcomes included SDH recurrence, postoperative infections, and drain complications. OsteoplugTM-C patients had significantly higher satisfaction and quality of life compared to those without a burrhole cover (ANA: 9 [7, 9] vs. 7 [5, 8], p = 0.019; VAS: 85 [75, 90] vs. 70 [50, 80], p = 0.021), and the absence of a burrhole cover was associated with poorer aesthetic outcomes after multivariable adjustment (adjusted OR: 4.55, 95% CI: 1.09-22.68, p = 0.047). No significant differences in other clinical outcomes were observed between OsteoplugTM-C, OsteoplugTM, or no burrhole cover. Our pilot study supports OsteoplugTM-C and its material polycaprolactone as suitable adjuncts to burrhole craniostomy, improving cosmetic outcomes while achieving comparable safety outcomes.

Controversies in the Surgical Treatment of Chronic Subdural Hematoma: A Systematic Scoping Review

Chronic subdural hematoma (cSDH) is one of the most common neurosurgical entities, especially in the elderly population. Diagnosis is usually established via a head computed tomography, while an increasing number of studies are investigating biomarkers to predict the natural history of cSDH, including progression and recurrence. Surgical evacuation remains the mainstay of treatment in the overwhelming majority of cases. Nevertheless, many controversies are associated with the nuances of surgical treatment. We performed a systematic review of the literature between 2010 and 2022, aiming to identify and address the issues in cSDH surgical management where consensus is lacking. The results show ambiguous data in regard to indication, the timing and type of surgery, the duration of drainage, concomitant membranectomy and the need for embolization of the middle meningeal artery. Other aspects of surgical treatment-such as the use of drainage and its location and number of burr holes-seem to have been adequately clarified: the drainage of hematoma is strongly recommended and the outcome is considered as independent of drainage location or the number of burr holes.