1
|
Ni Z, Zhu Y, Qian Y, Li X, Xing Z, Zhou Y, Chen Y, Huang L, Yang J, Zhuge Q. Synthetic minority over-sampling technique-enhanced machine learning models for predicting recurrence of postoperative chronic subdural hematoma. Front Neurol 2024; 15:1305543. [PMID: 38711558 PMCID: PMC11071664 DOI: 10.3389/fneur.2024.1305543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 03/28/2024] [Indexed: 05/08/2024] Open
Abstract
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.
Collapse
Affiliation(s)
- Zhihui Ni
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yehao Zhu
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yiwei Qian
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xinbo Li
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zhenqiu Xing
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yinan Zhou
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yu Chen
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Lijie Huang
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jianjing Yang
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Qichuan Zhuge
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| |
Collapse
|
2
|
Maeda T, Kikkawa Y, Ehara T, Tsuchiya R, Tabata S, Onodera K, Kimura T, Take Y, Suzuki K, Kurita H. Clinical Outcomes in Elderly Patients with Chronic Subdural Hematoma: Validation of Irrigation Assignment Based on Hematoma Characteristics. Life (Basel) 2024; 14:518. [PMID: 38672788 PMCID: PMC11051316 DOI: 10.3390/life14040518] [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: 03/13/2024] [Revised: 04/13/2024] [Accepted: 04/14/2024] [Indexed: 04/28/2024] Open
Abstract
The number of elderly patients with chronic subdural hematomas (CSDH) is increasing worldwide; however, there is limited data regarding the clinical outcomes in this population. Our therapeutic method using burr hole evacuation for CSDH is based on the hematoma characteristics, using simple drainage for single-layer lesions and drainage with irrigation for multiple-layer lesions. This study aimed to compare the postoperative outcomes of elderly and younger patients, identify the predictors of outcomes in elderly patients, and verify the validity of our therapeutic methods. In total, we included 214 patients who underwent burr hole evacuation between April 2018 and March 2022. Baseline characteristics, hematoma characteristics, recurrence, and clinical outcomes were compared between the elderly and younger patients. Overall, 96 elderly patients (44.9%) were included in the study, and more elderly patients underwent antithrombotic therapy than younger patients (33.3% vs. 19.5%, p = 0.027). Moreover, elderly patients had significantly fewer favorable outcomes than younger patients (70.8% vs. 91.5%; p < 0.001); however, this was not significant after adjusting for the baseline modified Rankin Scale (mRS). Similarly, elderly patients had higher recurrence rates than younger patients (10.4% vs. 2.5%; p = 0.021). However, the baseline mRS score was the only predictor of unfavorable outcomes. In conclusion, although the clinical outcomes of elderly patients were comparable to those of younger patients, the higher rate of preoperative antithrombotic therapy in elderly patients may result in a higher rate of recurrence requiring a long-term follow-up.
Collapse
Affiliation(s)
- Takuma Maeda
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka 350-1298, Japan
| | - Yuichiro Kikkawa
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka 350-1298, Japan
- Department of Neurosurgery, Saitama Cardiovascular and Respiratory Center, Kumagaya 360-0197, Japan
| | - Takuro Ehara
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka 350-1298, Japan
| | - Ryosuke Tsuchiya
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka 350-1298, Japan
| | - Shinya Tabata
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka 350-1298, Japan
| | - Koki Onodera
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka 350-1298, Japan
| | - Tatsuki Kimura
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka 350-1298, Japan
| | - Yushiro Take
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka 350-1298, Japan
| | - Kaima Suzuki
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka 350-1298, Japan
| | - Hiroki Kurita
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka 350-1298, Japan
| |
Collapse
|
3
|
Thapa P, Bhattarai G, Kharel SK, Kunwar P, Bhandari S, Bhandari S, Shilpakar S, Thapa B, Thapa A, Sharma MR. Endovascular treatment of subdural haematoma in patient under anti-platelet therapy: a case report. Ann Med Surg (Lond) 2024; 86:1066-1071. [PMID: 38333269 PMCID: PMC10849360 DOI: 10.1097/ms9.0000000000001516] [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: 09/10/2023] [Accepted: 11/06/2023] [Indexed: 02/10/2024] Open
Abstract
Introduction The incidence of chronic subdural haematoma (cSDH) is relatively high among the elderly population. Other known risk factors for cSDH include male sex, dependency on anti-platelet or anticoagulant medication, and chronic alcoholism. Although, the standard mode of treatment for cSDH is surgery, embolization of the middle meningeal artery (MMA), either upfront or as an adjunct to surgical evacuation can be used for the treatment of cSDH. Case presentation The authors present a case of a 75-year-old female with prior history of posterior-lateral wall myocardial infarction (MI) eight years back presented to our centre with the chief complaints of a gradual onset of cough and headache for 2 months. The patient had no history of trauma, loss of consciousness, seizures, and vomiting. There was no history of diabetes, hypertension, pulmonary tuberculosis, and other chronic illness. Discussion The concurrent use of anti- platelet drug during a surgical procedure can make the treatment challenging. Endovascular treatment can be a primary treatment modality in such situation. Conclusion Elimination of blood supply by middle meningeal artery embolization is emerging as a safe, minimally invasive alternative to treat cSDH.
Collapse
Affiliation(s)
| | - Ganesh Bhattarai
- Maharajgunj Medical Campus, Tribhuvan University, Institute of Medicine, Maharajgunj
| | - Santosh Kumar Kharel
- Maharajgunj Medical Campus, Tribhuvan University, Institute of Medicine, Maharajgunj
| | | | | | - Shailaj Bhandari
- Nepal Medical College Teaching Hospital, Jorpati, Katmandu, Nepal
| | | | | | | | | |
Collapse
|
4
|
Miyakoshi A, Nakatani E, Kaneda H, Hawke P, Sasaki H, Urano T, Miyachi Y. Administration of Tranexamic Acid After Burr Hole Craniotomy Reduced Postoperative Recurrence of Chronic Subdural Hematoma in a Japanese Regional Population. Neurosurgery 2023; 93:1160-1167. [PMID: 37288980 DOI: 10.1227/neu.0000000000002558] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 04/17/2023] [Indexed: 06/09/2023] Open
Abstract
BACKGROUND Although tranexamic acid (TXA) has occasionally been used to prevent postoperative recurrence of chronic subdural hematoma (CSDH) after burr hole craniotomy (BC), robust evidence of its efficacy has been lacking. OBJECTIVE To assess the efficacy and safety of postoperative oral administration of TXA after BC for CSDH among the elderly. METHODS This retrospective, propensity score-matched cohort study was carried out with a large Japanese local population-based longitudinal cohort in the Shizuoka Kokuho Database between April 2012 and September 2020. Patients included were age 60 years or older and had undergone BC for CSDH but were not undergoing dialysis. Covariates were collected from records of the preceding 12 months from the month of first BC, and patients were followed up for 6 months after surgery. The primary outcome was repeat surgery, and the secondary outcome was death or the onset of thrombosis. Data on postoperative TXA administration were collected and compared with controls using propensity score matching. RESULTS Of the 8544 patients who underwent BC for CSDH, 6647 were included, with 473 placed in the TXA group and 6174 placed in the control group. After 1:1 matching, repeated BC was found to have been performed in 30 of 465 patients (6.5%) in the TXA group and in 78 of 465 patients (16.8%) in the control group (relative risk, 0.38; 95% CI, 0.26-0.56). No significant difference was observed for death or the onset of thrombosis. CONCLUSION Oral administration of TXA reduced the occurrence of repeat surgery after BC for CSDH.
Collapse
Affiliation(s)
- Akinori Miyakoshi
- Shizuoka Graduate University of Public Health, Shizuoka , Japan
- Department of Neurosurgery, Shizuoka General Hospital, Shizuoka , Japan
| | - Eiji Nakatani
- Shizuoka Graduate University of Public Health, Shizuoka , Japan
| | - Hideaki Kaneda
- Translational Research Center for Medical Innovation, Foundation for Biomedical Research and Innovation at Kobe, Hyogo , Japan
| | - Philip Hawke
- School of Pharmaceutical Sciences, University of Shizuoka, Shizuoka , Japan
| | - Hatoko Sasaki
- Shizuoka Graduate University of Public Health, Shizuoka , Japan
| | - Tetsumei Urano
- Shizuoka Graduate University of Public Health, Shizuoka , Japan
| | - Yoshiki Miyachi
- Shizuoka Graduate University of Public Health, Shizuoka , Japan
| |
Collapse
|
5
|
Zhang P, Wang H, Bao H, Wang N, Chen Z, Tu Q, Lin X, Li Y, Zheng Z, Chen Y, Ruan L, Zhuge Q. Non-invasive Liver Fibrosis Scores Are Associated With Recurrence of Postoperative Chronic Subdural Hematoma. Front Neurol 2022; 13:873124. [PMID: 35769370 PMCID: PMC9236226 DOI: 10.3389/fneur.2022.873124] [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: 02/10/2022] [Accepted: 04/29/2022] [Indexed: 11/13/2022] Open
Abstract
Objective Although liver diseases have already been identified as a risk factor for increased recurrence and mortality in patients with chronic subdural hematoma (CSDH), the association between subclinical liver disease, specifically liver fibrosis (LF), and CSDH remains unknown. In the present study, we aimed to investigate the association between the LF scores and CSDH recurrence. Methods We retrospectively analyzed consecutive patients with CSDH who underwent burr-hole irrigation in the First Affiliated Hospital of Wenzhou Medical University between January 2015 and December 2018. The clinical data were collected, and the LF scores were calculated including aspartate aminotransferase–platelet ratio index (APRI), fibrosis-4 (FIB-4), and Forns index. Multivariable logistic regression analysis was applied to identify the association between the LF scores and CSDH recurrence, and Cox regression model and Fine–Gray competing risks model were performed to calculate hazard ratios (HRs) for CSDH recurrence based on time-to-event outcomes. The C-statistic, the integrated discrimination improvement (IDI), and the net reclassification improvement (NRI) evaluated the additive value of the LF scores to predict the recurrence of CSDH. Results A total of 419 patients with CSDH were included, hematoma recurrence was observed in 62 patients (14.80%) within 1 year after surgery. The LF scores were significantly higher in those who recurred, whereas the standard hepatic assays were mostly normal. The patients were assigned to groups of high and low LF scores based on the validated cut-offs; compared with the subjects with low scores, those with high score levels had significantly higher recurrence rates. After adjusting for potential confounders, the LF scores were independently associated with CSDH recurrence, multivariable-adjusted HRs (95% CI) for those with higher levels of APRI, FIB-4, and Forns score were 4.32 (1.37–13.60), 2.56 (1.20–5.43), and 2.02 (1.07–3.79) for the recurrence of CSDH, respectively. Moreover, adding the APRI to the conventional model improved the C-statistic from 0.731 to 0.763, with an NRI and IDI of 7.50 and 1.35%, respectively. Two further commonly-used LF score indices (FIB-4 score and Forns index) yielded comparable results. Conclusions The data from this study first indicated that the high LF scores were significantly associated with the recurrence of CSDH and that careful follow-up in these patients may be needed.
Collapse
Affiliation(s)
- Peng Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Hua Wang
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Han Bao
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Ning Wang
- Neurointerventional Department, Zhejiang Hospital, Hangzhou, China
| | - Zhen Chen
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Qi Tu
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiao Lin
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yun Li
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zezheng Zheng
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yu Chen
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Linhui Ruan
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- *Correspondence: Linhui Ruan
| | - Qichuan Zhuge
- Department of Neurosurgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Zhejiang Provincial Key Laboratory of Aging and Neurological Disorder Research, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Qichuan Zhuge
| |
Collapse
|
6
|
Bounajem MT, Campbell RA, Denorme F, Grandhi R. Paradigms in chronic subdural hematoma pathophysiology: Current treatments and new directions. J Trauma Acute Care Surg 2021; 91:e134-e141. [PMID: 34538825 DOI: 10.1097/ta.0000000000003404] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
ABSTRACT Chronic subdural hematomas (CSDHs) are an increasingly common pathology encountered in a neurosurgical trauma practice. Although the operative and nonoperative management of CSDH has been studied extensively, the recurrence rate of CSDH remains high, with no significant decrease in recent years. We undertook a detailed assessment of the known pathophysiological mechanisms by which CSDHs recur to improve our ability to treat patients with this disease successfully. In this review of the literature from the PubMed and Scopus databases, we used the search terms "(pathophysiology) AND chronic subdural hematoma [tiab]" to identify pertinent reviews and articles in English. The results demonstrated a complex inflammatory response to subdural blood, which begins with the formation of a collagen neomembrane around the clot itself. Proinflammatory mediators, such as vascular endothelial growth factor, interleukin-6, interleukin-8, tissue necrosis factor α, matrix metalloproteinases, and basic fibroblast growth factor, then contribute to chronic microbleeding by promoting the formation of fragile, leaky blood vessels, and widening of gap junctions of existing vessels. It is evident that the lack of improvement in recurrence rate is due to pathological factors that are not entirely alleviated by simple subdural evacuation. Targeted approaches, such as middle meningeal artery embolization and anti-inflammatory therapies, have become increasingly common and require further prospective analysis to aid in the determination of their efficacy.
Collapse
Affiliation(s)
- Michael T Bounajem
- From the Department of Neurosurgery, Clinical Neurosciences Center (M.T.B., R.G.), Molecular Medicine Program (R.A.C., F.D.); and Department of Internal Medicine (R.A.C.), University of Utah, Salt Lake City, Utah
| | | | | | | |
Collapse
|
7
|
Xu X, Wang D, Han Z, Wang B, Gao W, Fan Y, Li F, Zhou Z, Gao C, Xiong J, Zhou S, Zhang S, Yang G, Jiang R, Zhang J. A novel rat model of chronic subdural hematoma: Induction of inflammation and angiogenesis in the subdural space mimicking human-like features of progressively expanding hematoma. Brain Res Bull 2021; 172:108-119. [PMID: 33932488 DOI: 10.1016/j.brainresbull.2021.04.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 04/23/2021] [Accepted: 04/24/2021] [Indexed: 12/11/2022]
Abstract
Pathophysiological mechanisms of chronic subdural hematoma (CSDH) involve localized inflammation, angiogenesis, and dysregulated coagulation and fibrinolysis. The scarcity of reproducible and clinically relevant animal models of CSDH hinders further understanding the underlying pathophysiology and improving new treatment strategies. Here, we developed a novel rat model of CSDH using extracellular matrices (Matrigel) and brain microvascular endothelial cell line (bEnd.3 cells). One hundred-microliter of Matrigel-bEnd.3 cell (106 cells per milliliter) mixtures were injected into the virtual subdural space of elderly male Sprague-Dawley rats. This approach for the first time led to a spontaneous and expanding subdural hematoma, encapsulated by internal and external neomembranes, formed as early as 3 d, reached its peak at 7 d, and lasted for more than 14 d, mimicking the progressive hemorrhage observed in patients with CSDH. The external neomembrane and hematoma fluid involved numerous inflammatory cells, fibroblasts, and highly fragile neovessels. Furthermore, a localized pathophysiological process was validated as evidenced by the increased expressions of inflammatory and angiogenic mediators in external neomembrane and hematoma fluid rather than in peripheral blood. Notably, the specific expression profiles of these mediators were closely associated with the dynamic changes in hematoma volume and neurological outcome. In summary, the CSDH model described here replicated the characteristics of human CSDH, and might serve as an ideal translational platform for preclinical studies. Meanwhile, the crucial roles of angiogenesis and inflammation in CSDH formation were reaffirmed.
Collapse
Affiliation(s)
- Xin Xu
- Department of Neurosurgery, Tianjin Medical University General Hospital, 154 Anshan Road, Tianjin, 300052, China; Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, 154 Anshan Road, Tianjin, 300052, China; Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Beijing, 100053, China
| | - Dong Wang
- Department of Neurosurgery, Tianjin Medical University General Hospital, 154 Anshan Road, Tianjin, 300052, China; Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, 154 Anshan Road, Tianjin, 300052, China
| | - Zhenying Han
- Department of Neurosurgery, Tianjin Medical University General Hospital, 154 Anshan Road, Tianjin, 300052, China; Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, 154 Anshan Road, Tianjin, 300052, China
| | - Bo Wang
- Department of Neurosurgery, Tianjin Medical University General Hospital, 154 Anshan Road, Tianjin, 300052, China; Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, 154 Anshan Road, Tianjin, 300052, China
| | - Weiwei Gao
- Department of Neurology, Tianjin Huanhu Hospital, 6 Jizhao Road, Tianjin, 300350, China
| | - Yueshan Fan
- Department of Neurosurgery, Tianjin Medical University General Hospital, 154 Anshan Road, Tianjin, 300052, China; Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, 154 Anshan Road, Tianjin, 300052, China
| | - Fanjian Li
- Department of Neurosurgery, Tianjin Medical University General Hospital, 154 Anshan Road, Tianjin, 300052, China; Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, 154 Anshan Road, Tianjin, 300052, China
| | - Ziwei Zhou
- Department of Neurosurgery, Tianjin Medical University General Hospital, 154 Anshan Road, Tianjin, 300052, China; Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, 154 Anshan Road, Tianjin, 300052, China
| | - Chuang Gao
- Department of Neurosurgery, Tianjin Medical University General Hospital, 154 Anshan Road, Tianjin, 300052, China; Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, 154 Anshan Road, Tianjin, 300052, China
| | - Jianhua Xiong
- Department of Neurosurgery, Tianjin Medical University General Hospital, 154 Anshan Road, Tianjin, 300052, China; Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, 154 Anshan Road, Tianjin, 300052, China
| | - Shuai Zhou
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, 154 Anshan Road, Tianjin, 300052, China
| | - Shu Zhang
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, 154 Anshan Road, Tianjin, 300052, China
| | - Guili Yang
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, 154 Anshan Road, Tianjin, 300052, China
| | - Rongcai Jiang
- Department of Neurosurgery, Tianjin Medical University General Hospital, 154 Anshan Road, Tianjin, 300052, China; Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, 154 Anshan Road, Tianjin, 300052, China.
| | - Jianning Zhang
- Department of Neurosurgery, Tianjin Medical University General Hospital, 154 Anshan Road, Tianjin, 300052, China; Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, 154 Anshan Road, Tianjin, 300052, China.
| |
Collapse
|
8
|
Zhang P, Li Y, Huang J, Zhang H, Wang X, Dong L, Yan Z, She L. Chronic subdural haematoma in antithrombotic cohorts: characteristics, surgical outcomes, and recurrence. Br J Neurosurg 2020; 34:408-415. [DOI: 10.1080/02688697.2020.1749987] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Peng Zhang
- Department of Neurosurgery, DaLian Medical University, DaLian, China
| | - Yuping Li
- Department of Neurosurgery, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Jiannan Huang
- Department of Neurosurgery, DaLian Medical University, DaLian, China
| | - Hengzhu Zhang
- Department of Neurosurgery, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Xiaodong Wang
- Department of Neurosurgery, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Lun Dong
- Department of Neurosurgery, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Zhengcun Yan
- Department of Neurosurgery, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Lei She
- Department of Neurosurgery, Clinical Medical College of Yangzhou University, Yangzhou, China
| |
Collapse
|
9
|
Du B, Xu J, Hu J, Zhong X, Liang J, Lei P, Wang H, Li W, Peng Y, Shan A, Zhang Y. A Clinical Study of the Intra-Neuroendoscopic Technique for the Treatment of Subacute-Chronic and Chronic Septal Subdural Hematoma. Front Neurol 2020; 10:1408. [PMID: 32010057 PMCID: PMC6979069 DOI: 10.3389/fneur.2019.01408] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 12/23/2019] [Indexed: 11/17/2022] Open
Abstract
Objective: The surgical technique, safety, efficacy, and clinical application value of the intra-neuroendoscopic technique (INET) for the treatment of subacute-chronic and chronic septal subdural hematoma was investigated based on the structure and pathological features of the hematoma wall, and the critical factors of hematoma growth and recurrence were determined, in order to provide reference for clinical drug treatment. Methods: This was non-randomized concurrent control study. A total of 94 patients who met the inclusion criteria were recruited between May 2015 and February 2019 and were divided into the INET treatment group (INET group, 45 cases) and the burr hole drainage (BHD) treatment group (control group, 49 cases). The hematoma fluid components and the morphological structure and pathological characteristics of the hematoma wall were analyzed, and the surgical duration, subdural drainage tube (SDT) placement duration, intracranial infection rate, Bender grade at the 1 month post-operative follow-up and hematoma recurrence rate within the 6 months of post-operative follow-up were compared between the two groups. A multiple logistic regression model was established to analyze the risk factors associated with recurrence within 6 months. Results: Intraoperative endoscopy showed that the adhesion bands that formed early in the hematoma cavity were strip-like and that those that formed late were lock-column-like. The hematoma cavity was divided into different-sized chambers with by these strips/columns. Pathological sections of cyst wall reveled angiogenesis inside the cyst and mucus-like changes, rupture and hemorrhage in the vascular wall. Obvious inflammatory cell infiltration and fibrous connective tissue hyperplasia were observed in the cyst wall. The osmotic pressure of the hematoma fluid was not significantly different from that of the peripheral venous blood [(296.7 ± 10.3) mOsm/kg vs. (291.5 ± 12.4) mOsm/kg, p = 0.68]. However, the D-dimer contents which reflect the severity of fibrinolysis in the hematoma and the proinflammatory cytokine interleukin 6 (IL-6) were significantly higher in the hematoma fluid than in the peripheral venous blood. The surgery duration for the INET group was significantly longer than that for the control group [(60.4 ± 10.6) min vs. (44.1 ± 9.8) min, p = 0.00], but both the hematoma recurrence rate within 6 months of post-operative follow-up (4.4 vs. 24.5%, p = 0.00) and the SDT placement duration [(2.1 ± 0.6) d vs. (3.9 ± 0.7) d, p = 0.00] for the INET group were both lower than those for the control group. The intracranial infection rate did not differ significantly between the two groups (4.4 vs. 10.2%, p = 0.50). The overall effective rate of the Bender grade at 1 month of follow-up did not differ significantly between the two groups (95.6 vs. 87.8%, p = 0.32), but the proportion of patients who recovered to Bender grade 0 with no symptoms was significantly higher in the INET group than in the control group (86.7 vs. 67.3%, p = 0.03). Multiple logistic regression analysis showed that INET surgery [odds ratio (OR) 3.71, 95% confidence interval (CI) 1.31–9.62, p = 0.02], age of 65 years or younger (OR 1.51, 95% CI 1.05–2.87, p = 0.03) and unilateral subdural hematoma (OR 1.76, 95% CI 1.05–3.41, p = 0.02) were independent factors that reduced the post-operative recurrence rate. Conclusion: The INET surgical plan based on the structure and pathological features of the subacute-chronic and chronic subdural hematoma wall can reduce the recurrence rate and improve the clinical prognosis. Trial registration:ClinicalTrials.gov, NCT02515903. Registered 5 August, 2015.
Collapse
Affiliation(s)
- Bo Du
- Department of Emergency, Shenzhen People's Hospital, The Second Clinical Medical College of Jinan University, The First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, China
| | - Jianzhong Xu
- Department of Emergency, Shenzhen People's Hospital, The Second Clinical Medical College of Jinan University, The First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, China
| | - Jintao Hu
- Department of Pathology, Shenzhen People's Hospital, The Second Clinical Medical College of Jinan University, The First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, China
| | - Xianliang Zhong
- Department of Emergency, Shenzhen People's Hospital, The Second Clinical Medical College of Jinan University, The First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, China
| | - Jian Liang
- Department of Neurosurgery, Shenzhen People's Hospital, The Second Clinical Medical College of Jinan University, The First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, China
| | - Pengfei Lei
- Department of Emergency, Shenzhen People's Hospital, The Second Clinical Medical College of Jinan University, The First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, China
| | - Hao Wang
- Department of Emergency, Shenzhen People's Hospital, The Second Clinical Medical College of Jinan University, The First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, China
| | - Weichun Li
- Department of Emergency, Shenzhen People's Hospital, The Second Clinical Medical College of Jinan University, The First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, China
| | - Yuping Peng
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Aijun Shan
- Department of Emergency, Shenzhen People's Hospital, The Second Clinical Medical College of Jinan University, The First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, China
| | - Yujuan Zhang
- Department of Ultrasound, Shenzhen People's Hospital, The Second Clinical Medical College of Jinan University, The First Affiliated Hospital of Southern University of Science and Technology, Shenzhen, China
| |
Collapse
|
10
|
Duy LA, Small JE. Subdural Hemorrhage and Posttraumatic Hygroma. Neuroradiology 2019. [DOI: 10.1016/b978-0-323-44549-8.00002-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
11
|
Wakuta N, Abe H, Nonaka M, Morishita T, Higashi T, Arima H, Inoue T. Analysis of Endoscopic Findings in the Chronic Subdural Hematoma Cavity: Bleeding Factors in Chronic Subdural Hematoma Natural History and as Predictors of Recurrence. World Neurosurg 2018; 124:S1878-8750(18)32901-2. [PMID: 30593956 DOI: 10.1016/j.wneu.2018.12.078] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 12/14/2018] [Accepted: 12/17/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Possible factors associated with bleeding from endoscopy-detected chronic subdural hematomas (CSDHs) have rarely been analyzed. We therefore evaluated intraoperative endoscopic findings to elucidate the clinical course and assess predictors of CSDH recurrence. METHODS Altogether, 540 CSDHs were reviewed in this retrospective study. Six possible signs of bleeding were detected in the cavity: spotty bleeding on the outer membrane, hematoma clots, cerebral parenchymal suspension, stretched cortical vessels, intraluminal trabecular structures, and septa separating the cavity. We evaluated the association of each with the radiologic findings, endoscopic features, and interval from trauma to surgery and then assessed the correlation between each endoscopic feature and CSDH recurrence. RESULTS Spotty bleeding, cerebral parenchymal suspension, and stretched cortical vessels occurred during every period. Hematoma clots exhibited a 2-peak pattern with significant resurgence during the chronic phase. Trabecular structures significantly increased 61 days after the trauma, reaching 71.2% of patients on day 91. Septa were found in the cavity in only 12.5% during the initial 30 days but subsequently increased significantly to 37.3%. At 2 months, an exacerbation stage was inferred. The multivariable analysis revealed that trabecular structures and residual septa were significant independent risk factors for recurrence. We opened most septa intraoperatively. Their recurrence rate was 7.5%, which is lower than has been previously reported. CONCLUSIONS Evaluation of the changes in the endoscopic findings and their association with recurrence was useful for clarifying the mechanism of CSDH enlargement, the risk of recurrence, and the potential for endoscopic surgery.
Collapse
Affiliation(s)
- Naoki Wakuta
- Department of Neurosurgery, Fukuoka University Hospital, and School of Medicine, Fukuoka University, Fukuoka, Japan.
| | - Hiroshi Abe
- Department of Neurosurgery, Fukuoka University Hospital, and School of Medicine, Fukuoka University, Fukuoka, Japan
| | - Masani Nonaka
- Department of Neurosurgery, Fukuoka University Hospital, and School of Medicine, Fukuoka University, Fukuoka, Japan
| | - Takashi Morishita
- Department of Neurosurgery, Fukuoka University Hospital, and School of Medicine, Fukuoka University, Fukuoka, Japan
| | - Toshio Higashi
- Department of Neurosurgery, Fukuoka University Hospital, and School of Medicine, Fukuoka University, Fukuoka, Japan
| | - Hisatomi Arima
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Tooru Inoue
- Department of Neurosurgery, Fukuoka University Hospital, and School of Medicine, Fukuoka University, Fukuoka, Japan
| |
Collapse
|
12
|
Fomchenko EI, Gilmore EJ, Matouk CC, Gerrard JL, Sheth KN. Management of Subdural Hematomas: Part II. Surgical Management of Subdural Hematomas. Curr Treat Options Neurol 2018; 20:34. [PMID: 30019165 DOI: 10.1007/s11940-018-0518-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Management of patients with subdural hematomas starts with Emergency Neurological Life Support guidelines. Patients with acute or chronic subdural hematomas (SDHs) associated with rapidly deteriorating neurologic exam, unilaterally or bilaterally dilated nonreactive pupils, and extensor posturing are considered imminently surgical; likewise, SDHs more than 10 mm in size or those associated with more than 5-mm midline shift are deemed operative. RECENT FINDINGS While twist drill craniostomy and placement of subdural evacuating vport system (SEPS) are quick, bedside procedures completed under local anesthesia and appropriate for patients with chronic SDH or patients that cannot tolerate anesthesia, these techniques are not optimal for patients with acute SDH or chronic SDH with septations. Burr hole SDH evacuation under conscious sedation or general anesthesia is an analogous technique; however, it requires basic surgical equipment and operating room staff, with a focus on a closed system with burr hole followed by rapid drain placement to avoid introduction of air into the subdural space, or multiple burr holes with extensive irrigation to reduce pneumocephalus and continue SDH evacuation via drain for several days. Acute SDH associated with significant mass effect and cerebral edema requires aggressive decompression via craniotomy with clot evacuation and frequently a craniectomy. Chronic SDHs that fail conservative management and progress clinically or radiographically are addressed with craniotomy with or without membranectomy. Surgical SDH management is variable depending on its characteristics and etiology, patient's functional status, comorbidities, goals of care, institutional preferences, and availability of specialized surgical equipment and adjunct therapies. Rapid access to surgical suites and trained staff to address surgical hemorrhages in a timely manner, with appropriate post-operative care by a specialized team including neurosurgeons and neurointensivists, is of paramount importance for successful patient outcomes. Here, we review various aspects of surgical SDH management.
Collapse
Affiliation(s)
- Elena I Fomchenko
- Department of Neurosurgery, Yale University, 20 York St, New Haven, CT, USA.
| | - Emily J Gilmore
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
- Division of Neuro-Critical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Charles C Matouk
- Department of Neurosurgery, Yale University, 20 York St, New Haven, CT, USA
| | - Jason L Gerrard
- Department of Neurosurgery, Yale University, 20 York St, New Haven, CT, USA
| | - Kevin N Sheth
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
- Division of Neuro-Critical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
- Department of Clinical Neurosciences, Yale University, 20 York St, New Haven, CT, USA
| |
Collapse
|
13
|
Abstract
PURPOSE OF REVIEW Subdural hematomas (SDH) represent common neurosurgical problem associated with significant morbidity, mortality, and high recurrence rates. SDH incidence increases with age; numbers of patients affected by SDH continue to rise with our aging population and increasing number of people taking antiplatelet agents or anticoagulation. Medical and surgical SDH management remains a subject of investigation. RECENT FINDINGS Initial management of patients with concern for altered mental status with or without trauma starts with Emergency Neurological Life Support (ENLS) guidelines, with a focus on maintaining ICP < 22 mmHg, CPP > 60 mmHg, MAP 80-110 mmHg, and PaO2 > 60 mmHg, followed by rapid sequence intubation if necessary, and expedited acquisition of imaging to identify a space-occupying lesion. Patients are administered anti-seizure medications, and their antiplatelet medications or anticoagulation may be reversed if neurosurgical interventions are anticipated, or until hemorrhage is stabilized on imaging. Medical SDH care focuses on (a) management of intracranial hypertension; (b) maintenance of adequate cerebral perfusion; (c) seizure prevention and treatment; (d) maintenance of normothermia, eucarbia, euglycemia, and euvolemia; and (e) early initiation of enteral feeding, mobilization, and physical therapy. Post-operatively, SDH patients require ICU level care and are co-managed by neurointensivists with expertise in treating increased intracranial pressure, seizures, and status epilepticus, as well as medical complications of critical illness. Here, we review various aspects of medical management with a brief overview of pertinent literature and clinical trials for patients diagnosed with SDH.
Collapse
|
14
|
Cattalani A, Grasso VM, Vitali M, Gallesio I, Magrassi L, Barbanera A. Transcranial color-coded duplex sonography for evaluation of midline-shift after chronic-subdural hematoma evacuation (TEMASE): A prospective study. Clin Neurol Neurosurg 2017; 162:101-107. [DOI: 10.1016/j.clineuro.2017.09.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Revised: 09/25/2017] [Accepted: 09/30/2017] [Indexed: 12/19/2022]
|
15
|
Tanweer O, Frisoli FA, Bravate C, Harrison G, Pacione D, Kondziolka D, Huang PP. Tranexamic Acid for Treatment of Residual Subdural Hematoma After Bedside Twist-Drill Evacuation. World Neurosurg 2016; 91:29-33. [DOI: 10.1016/j.wneu.2016.03.062] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Revised: 03/18/2016] [Accepted: 03/21/2016] [Indexed: 11/24/2022]
|
16
|
Abstract
Chronic subdural hematoma (CSDH) is one of the most common neurosurgical conditions. There is lack of uniformity in the treatment of CSDH amongst surgeons in terms of various treatment strategies. Clinical presentation may vary from no symptoms to unconsciousness. CSDH is usually diagnosed by contrast-enhanced computed tomography scan. Magnetic resonance imaging (MRI) scan is more sensitive in the diagnosis of bilateral isodense CSDH, multiple loculations, intrahematoma membranes, fresh bleeding, hemolysis, and the size of capsule. Contrast-enhanced CT or MRI could detect associated primary or metastatic dural diseases. Although definite history of trauma could be obtained in a majority of cases, some cases may be secondary to coagulation defect, intracranial hypotension, use of anticoagulants and antiplatelet drugs, etc., Recurrent bleeding, increased exudates from outer membrane, and cerebrospinal fluid entrapment have been implicated in the enlargement of CSDH. Burr-hole evacuation is the treatment of choice for an uncomplicated CSDH. Most of the recent trials favor the use of drain to reduce recurrence rate. Craniotomy and twist drill craniostomy also play a role in the management. Dural biopsy should be taken, especially in recurrence and thick outer membrane. Nonsurgical management is reserved for asymptomatic or high operative risk patients. The steroids and angiotensin converting enzyme inhibitors may also play a role in the management. Single management strategy is not appropriate for all the cases of CSDH. Better understanding of the nature of the pathology, rational selection of an ideal treatment strategy for an individual patient, and identification of the merits and limitations of different surgical techniques could help in improving the prognosis.
Collapse
Affiliation(s)
- Yad R Yadav
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Vijay Parihar
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Hemant Namdev
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Jitin Bajaj
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| |
Collapse
|
17
|
Park KS, Park SH, Hwang SK, Kim C, Hwang JH. Correlation of the Beta-trace protein and inflammatory cytokines with magnetic resonance imaging in chronic subdural hematomas : a prospective study. J Korean Neurosurg Soc 2015; 57:235-41. [PMID: 25932289 PMCID: PMC4414766 DOI: 10.3340/jkns.2015.57.4.235] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 01/06/2015] [Accepted: 02/13/2015] [Indexed: 11/27/2022] Open
Abstract
Objective Magnetic resonance imaging (MRI) of chronic subdural hematoma (CSDH) detects various patterns, which can be attributed to many factors. The purpose of this study was to measure the level of interleukin-6 (IL-6), interleukin-8 (IL-8), and highly specific protein [beta-trace protein (βTP)] for cerebrospinal fluid (CSF) in CSDHs, and correlate the levels of these markers with the MRI findings. Methods Thirty one patients, treated surgically for CSDH, were divided on the basis of MRI findings into hyperintense and non-hyperintense groups. The concentrations of IL-6, IL-8, and βTP in the subdural fluid and serum were measured. The βTP was considered to indicate an admixture of CSF to the subdural fluid if βTP in the subdural fluid (βTPSF)/βTP in the serum (βTPSER)>2. Results The mean concentrations of IL-6 and IL-8 of the hyperintense group (n=17) of T1-WI MRI were 3975.1±1040.8 pg/mL and 6873.2±6365.4 pg/mL, whereas them of the non-hyperintense group (n=14) were 2173.5±1042.1 pg/mL and 2851.2±6267.5 pg/mL (p<0.001 and p=0.004). The mean concentrations of βTPSF and the ratio of βTPSF/βTPSER of the hyperintense group (n=13) of T2-WI MRI were 7.3±2.9 mg/L and 12.6±5.4, whereas them of the non-hyperintense group (n=18) were 4.3±2.3 mg/L and 7.5±3.9 (p=0.011 and p=0.011). Conclusion The hyperintense group on T1-WI MRI of CSDHs exhibited higher concentrations of IL-6 and IL-8 than non-hyperintense group. And, the hyperintese group on T2-WI MRI exhibited higher concentrations of βTPSF and the ratio of βTPSF/βTPSER than non-hyperintense group. These findings appear to be associated with rebleeding and CSF admixture in the CSDHs.
Collapse
Affiliation(s)
- Ki-Su Park
- Department of Neurosurgery, Kyungpook National University School of Medicine, Daegu, Korea
| | - Seong-Hyun Park
- Department of Neurosurgery, Kyungpook National University School of Medicine, Daegu, Korea
| | - Sung-Kyoo Hwang
- Department of Neurosurgery, Kyungpook National University School of Medicine, Daegu, Korea
| | - Chaekyung Kim
- Department of Neurosurgery, Kyungpook National University School of Medicine, Daegu, Korea
| | - Jeong-Hyun Hwang
- Department of Neurosurgery, Kyungpook National University School of Medicine, Daegu, Korea
| |
Collapse
|
18
|
Oh JS, Shim JJ, Yoon SM, Lee KS. Influence of Gender on Occurrence of Chronic Subdural Hematoma; Is It an Effect of Cranial Asymmetry? Korean J Neurotrauma 2014; 10:82-5. [PMID: 27169039 PMCID: PMC4852622 DOI: 10.13004/kjnt.2014.10.2.82] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 10/01/2014] [Accepted: 10/03/2014] [Indexed: 11/15/2022] Open
Abstract
Objective Chronic subdural hematoma (CSDH) is a condition mostly present in older people. Men are more commonly affected than women. Several theories about male predominance could not enough to explain the reason for male predominance on CSDH. The purpose of this study is to find out whether there were any differences in the anatomy of cranium, which may contribute the pathogenesis or risk factors of CSDH. Methods The study population was consisted of 87 patients with CSDH and 100 patients with transient ischemic attack (TIA) from 2006 to 2013. We classified into four groups; group A (CSDH male 47), group B (CSDH female 40), group C (TIA male 50), and group D (TIA female 50). We measured the size of the cranium in the computed tomography scans, retrospectively. We define the difference of cranium (Dc), which is difference between the right and left radiuses. Results The Dc was significantly higher in patients with CSDH (group A and B)(p=0.03). The mean Dc was 3.49 mm in CSDH group (group A and B) and 2.14 mm in TIA group (group C and D). The mean Dc of CSDH group was significantly larger than that of TIA group (by t-test, p<0.01). Conclusion Size and asymmetry of the cranium may be a risk factor of CSDH. Gender differences in the anatomy of cranium may contribute pathogenesis of CSDH.
Collapse
Affiliation(s)
- Jae-sang Oh
- Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Jai-Joon Shim
- Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Seok-Mann Yoon
- Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Kyeong-Seok Lee
- Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| |
Collapse
|
19
|
Spontaneous Resolution of Nontraumatic Chronic Subdural Hematoma Associated With Anti-aggregation Therapy. J Craniofac Surg 2014; 25:e363-5. [DOI: 10.1097/scs.0000000000000814] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
|
20
|
Emich S, Richling B, McCoy MR, Al-Schameri RA, Ling F, Sun L, Wang Y, Hitzl W. The efficacy of dexamethasone on reduction in the reoperation rate of chronic subdural hematoma--the DRESH study: straightforward study protocol for a randomized controlled trial. Trials 2014; 15:6. [PMID: 24393328 PMCID: PMC3891985 DOI: 10.1186/1745-6215-15-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Accepted: 12/12/2013] [Indexed: 11/15/2022] Open
Abstract
Background Chronic subdural hematoma (cSDH) is a common neurosurgical disease. It is often considered to be a rather benign entity. In spite of well established surgical procedures cSDH is complicated by a recurrence rate up to 30%. Since glucocorticoids have been used for treatment of cSDH in 1962 their role is still discussed controversially in lack of evident data. On the basis of the ascertained inflammation cycle in cSDH dexamethasone will be an ideal substance for a short lasting, concomitant treatment protocol. Objective: to test the efficacy of dexamethasone on reduction inthe reoperation rate of cSDH. Methods/Design The study is designed as a double-blind randomized placebo-controlled trial 820 patients who are operated for cSDH and from the age of 25 years are included after obtaining informed consent. They are randomized for administration of dexamethasone (16-16-12-12-8-4 mg/d) or placebo (maltodextrin) during the first 48 hours after surgery. The type I error is 5% and the type II error is 20%. The primary endpoint is the reoperation within 12 weeks postoperative. Discussion This study tests whether dexamethasone administered over 6 days is a safe and potent agent in relapse prevention for evacuated cSDH. Trial registration EudraCT 201100354442
Collapse
Affiliation(s)
- Stephan Emich
- Christian Doppler Klinik, PMU Salzburg, Universitätsklinik für Neurochirurgie, Ignaz Harrer Str, 79, 5020 Salzburg, Austria.
| | | | | | | | | | | | | | | |
Collapse
|
21
|
Kitazono M, Yokota H, Satoh H, Onda H, Matsumoto G, Fuse A, Teramoto A. Measurement of inflammatory cytokines and thrombomodulin in chronic subdural hematoma. Neurol Med Chir (Tokyo) 2013. [PMID: 23183075 DOI: 10.2176/nmc.52.810] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Inflammation and the coagulation system may influence the genesis of chronic subdural hematoma (CSDH). The appearance of CSDH on computed tomography (CT) varies with the stage of the hematoma. This study investigated the pathogenesis and the recurrence of CSDH by comparing cytokine levels with the CT features of CSDH in 26 patients with 34 CSDHs who underwent single burr-hole surgery at our hospital between October 2004 and November 2006. The hematoma components removed during the procedure were examined, and the hematoma serum levels of cytokines measured such as thrombomodulin (TM), interleukin-6 (IL-6), tumor necrosis factor-α (TNFα), and interleukin-10 (IL-10). Using CT, mixed density hematomas were distinguished from other homogeneous hematomas, and found that the TM level was significantly higher in mixed density hematomas than in homogeneous hematomas (p = 0.043). Mixed density hematomas were classified into three subtypes (laminar, separated, and trabecular hematomas). The TM level was significantly higher in laminar and separated hematomas than in other hematomas (p = 0.01). The levels of IL-6, TNFα, and IL-10 were extremely high, but showed no significant differences in relation to the CT features. Mixed density hematomas had high recurrence rate, as reported previously, and TM level was high in mixed density hematomas such as laminar and separated mixed density hematomas. The present findings suggest that the types of CSDH associated with high TM levels tend to have higher recurrence rate.
Collapse
Affiliation(s)
- Masatoshi Kitazono
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan.
| | | | | | | | | | | | | |
Collapse
|
22
|
Son S, Yoo CJ, Lee SG, Kim EY, Park CW, Kim WK. Natural course of initially non-operated cases of acute subdural hematoma : the risk factors of hematoma progression. J Korean Neurosurg Soc 2013; 54:211-9. [PMID: 24278650 PMCID: PMC3836928 DOI: 10.3340/jkns.2013.54.3.211] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Revised: 02/03/2013] [Accepted: 08/19/2013] [Indexed: 11/27/2022] Open
Abstract
Objective The objectives of the present study were to characterize the natural course of initially non-operated traumatic acute subdural hematoma (ASDH) and to identify the risk factors of hematoma progression. Methods Retrospective analysis was performed using sequential computed tomography (CT) images maintained in a prospective observational database containing 177 ASDH cases treated from 2005 to 2011. Patients were allocated to four groups as followings; 136 (76.8%) patients to the spontaneous resolution group, 12 (6.8%) who underwent operation between 4 hours and 7 days to the rapid worsening group (RWG), 24 (13.6%) who experienced an increase of hematoma and that underwent operation between 7 and 28 days to the subacute worsening group (SWG), and 5 (2.8%) who developed delayed aggravation requiring surgery from one month after onset to the delayed worsening group (DWG). Groups were compared with respect to various factors. Results No significant intergroup difference was found with respect to age, mechanism of injury, or initial Glasgow Coma Scale. The presence of combined cerebral contusion or subarachnoid hemorrhage was found to be a significant prognostic factor. Regarding CT findings, mixed density was common in the RWG and the SWG. Midline shifting, hematoma thickness, and numbers of CT slices containing hematoma were significant prognostic factors of the RWG and the SWG. Brain atrophy was more severe in the SWG and the DWG. Conclusion A large proportion of initially non-operated ASDHs worsen in the acute or subacute phase. Patients with risk factors should be monitored carefully for progression by repeat CT imaging.
Collapse
Affiliation(s)
- Seong Son
- Department of Neurosurgery, Gachon University, Gil Medical Center, Incheon, Korea
| | | | | | | | | | | |
Collapse
|
23
|
Lee KS, Shim JJ, Yoon SM, Doh JW, Yun IG, Bae HG. Acute-on-Chronic Subdural Hematoma: Not Uncommon Events. J Korean Neurosurg Soc 2011; 50:512-6. [PMID: 22323938 DOI: 10.3340/jkns.2011.50.6.512] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2011] [Revised: 09/27/2011] [Accepted: 12/19/2011] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Patients with asymptomatic chronic subdural hematoma (SDH) are prone to fall or slip. Acute trauma on these patients may develop acute subdural bleeding over the chronic SDH. We recently experienced 9 patients with acute-on-chronic SDH. We report the clinical and radiological features of this lesion. METHODS We retrospectively examined the computed tomographic (CT) scans of 107 consecutive patients who diagnosed as chronic SDH from January 2008 to December 2010. All cases of CSDH were diagnosed on CT with or without MRI scan. RESULTS Acute-on-chronic SDH is not rare, being 8% of chronic SDH. The most common cause of trauma was a slip in drunken state. Alcoholism with multiple episodes of trauma was one of the prominent histories. Acute-on-chronic SDH appeared as a hyperdense layer of clot with irregular blurred margin or lumps in liquefied hematoma. Single or two burr holes was usually effective to remove the hematoma. CONCLUSION Repeated trauma may cause acute bleeding over the chronic SDH. It will be helpful to understand the role of repeated trauma as a mechanism of hematoma enlargement.
Collapse
Affiliation(s)
- Kyeong-Seok Lee
- Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | | | | | | | | | | |
Collapse
|