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Taj I, Nitasha F. Letter to the editor: Irrigation versus no irrigation in the treatment of chronic subdural hematoma: an updated systematic review and meta‑analysis of 1581 patients. Neurosurg Rev 2024; 47:394. [PMID: 39093450 DOI: 10.1007/s10143-024-02626-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2024] [Revised: 07/17/2024] [Accepted: 07/26/2024] [Indexed: 08/04/2024]
Affiliation(s)
- Iqra Taj
- Jinnah Sindh Medical University, Karachi, Pakistan.
| | - Fnu Nitasha
- Jinnah Sindh Medical University, Karachi, Pakistan
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Ramirez-Velandia F, Ranawaka KH, Wadhwa A, Salih M, Fodor TB, Lau TS, Pacheco-Barrios N, Enriquez-Marulanda A, Khan IS, Vega RA, Stippler M, Taussky P, Hong J, Ogilvy CS. Comparison of Postoperative Seizures Between Burr-Hole Evacuation and Craniotomy in Patients With Nonacute Subdural Hematomas: A Bi-Institutional Propensity Score-Matched Analysis. Neurosurgery 2024:00006123-990000000-01268. [PMID: 38967423 DOI: 10.1227/neu.0000000000003046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 04/23/2024] [Indexed: 07/06/2024] Open
Abstract
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.
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Affiliation(s)
- Felipe Ramirez-Velandia
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Kasuni H Ranawaka
- Neurosurgical Division, Dartmouth Hitchcook Medical Center, Hanover, New Hampshire, USA
- Dartmouth Geisel School of Medicine, Hanover, New Hampshire, USA
| | - Aryan Wadhwa
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Mira Salih
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Thomas B Fodor
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Tzak S Lau
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Niels Pacheco-Barrios
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Alejandro Enriquez-Marulanda
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Imad S Khan
- Neurosurgical Division, Dartmouth Hitchcook Medical Center, Hanover, New Hampshire, USA
- Dartmouth Geisel School of Medicine, Hanover, New Hampshire, USA
| | - Rafael A Vega
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Martina Stippler
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Philipp Taussky
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Jennifer Hong
- Neurosurgical Division, Dartmouth Hitchcook Medical Center, Hanover, New Hampshire, USA
- Dartmouth Geisel School of Medicine, Hanover, New Hampshire, USA
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Porto Junior S, Meira DA, da Cunha BLB, Fontes JHM, Pustilnik HN, Medrado Nunes GS, Cerqueira GA, Silva da Paz MGD, Alcântara T, Dourado JC, Miranda de Avelar L. Active Versus Passive Drainage Systems for Subdural Hematomas: A Systematic Review and Meta-Analysis. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01229. [PMID: 38967446 DOI: 10.1227/ons.0000000000001252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 04/30/2024] [Indexed: 07/06/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Chronic subdural hematoma (CSDH) management involves various surgical techniques, with drainage systems playing a pivotal role. While passive drainage (PD) and active drainage (AD) are both used, their efficacy remains contentious. Some studies favor PD for lower recurrence rates, while others suggest AD superiority. A systematic review and meta-analysis were conducted to address this controversy, aiming to provide clarity on optimal drainage modalities post-CSDH evacuation. METHODS This systematic review and meta-analysis followed preferred reporting items for systematic reviews guidelines, searching PubMed, Embase, and Web of Science until February 2024. Inclusion criteria focused on studies comparing active vs PD for subdural hematomas. Data extraction involved independent researchers, and statistical analysis was conducted using R software. The assessment of risk of bias was performed using the Risk of Bias in Non-Randomized Studies of Interventions framework and the Risk Of Bias 2 tool. RESULTS In this meta-analysis, involving 1949 patients with AD and 1346 with PD, no significant differences were observed in recurrence rates between the active (13.6%) and passive (16.4%) drainage groups (risk ratio [RR] = 0.87; 95% CI: 0.58-1.31). Similarly, for complications, infection, hemorrhage, and mortality, no significant disparities were found between the 2 drainage modalities. Complication rates were 7.5% for active and 12.6% for PD (RR = 0.74; 95% CI: 0.36-1.52). Infection rates were available for 635 patients of the active group, counting for 2% and 2.6%, respectively (RR = 0.98; 95% CI: 0.24-4.01). Hemorrhage rates were also available for 635 patients of the active group, counting for 1.1% and 2.2%, respectively (RR = 0.44; 95% CI: 0.11-1.81). Mortality rates were 2.7% and 2.5%, respectively (RR = 0.94; 95% CI: 0.61-1.46). CONCLUSION Our study found no significant difference between passive and AD for managing complications, recurrence, infection, hemorrhage, or mortality in CSDH cases. Further large-scale randomized trials are needed for clarity.
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Affiliation(s)
| | - Davi Amorim Meira
- Department of Medicine, Bahiana School of Medicine, Salvador, Bahia, Brazil
| | | | | | | | | | | | | | - Tancredo Alcântara
- Department of Neurosurgery, General Hospital Roberto Santos, Salvador, Bahia, Brazil
- Department of Neurosurgery, NICC-Núcleo Integrado do Cérebro e Coluna, Salvador, Bahia, Brazil
| | - Jules Carlos Dourado
- Department of Neurosurgery, General Hospital Roberto Santos, Salvador, Bahia, Brazil
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Omerhodžić I, Rovčanin B, Ećo I, Kudić B, Zahirović S, Džurlić A, Ahmetspahić A, Pojskić M. Comparison of outcomes and recurrence rates in patients undergoing single or double burr hole surgery for the treatment of chronic subdural hematoma in Bosnia and Herzegovina. BRAIN & SPINE 2024; 4:102863. [PMID: 39099766 PMCID: PMC11295928 DOI: 10.1016/j.bas.2024.102863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 06/30/2024] [Accepted: 07/03/2024] [Indexed: 08/06/2024]
Abstract
Introduction Chronic subdural hematoma (CSDH) is a prevalent condition commonly seen in elderly individuals, often requiring neurosurgical intervention. Research question This study investigates patient characteristics and recurrence rates in CSDH patients treated with single or double burr hole surgery in Bosnia and Herzegovina. Methods: A retrospective study was conducted on patients treated for CSDH between January 2018 and December 2022. The diagnosis of CSDH was confirmed through preoperative CT or MRI of the brain. Patients underwent either single or double burr hole surgery based on the neurosurgeon's decision. Preoperative and postoperative brain CT scans, along with clinical outcomes, were analyzed. Results A total of 87 patients were included in the study, with 102 burr hole surgeries performed. Among these, 49 patients received single burr hole surgery, while 53 patients underwent double burr hole surgery. Recurrence of CSDH occurred in 8.8% of cases, with no significant difference observed between the groups. Notably, single burr hole surgery demonstrated comparable efficacy to double burr hole surgery in terms of subdural reduction and occurrence of pneumocephalus, while exhibiting fewer complications and shorter hospitalization. Discussion and conclusions burr hole surgery, whether performed as a single or double procedure, is an effective treatment option for CSDH, as it leads to positive outcomes in both radiological and clinical assessments of patients following surgery. The population of Bosnia and Herzegovina receives good neurosurgical care for CSDH.
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Affiliation(s)
- Ibrahim Omerhodžić
- Department of Neurosurgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
- Faculty of Medicine, University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Bekir Rovčanin
- Department of Neurosurgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
- Faculty of Medicine, University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Ismar Ećo
- International Patient Services Department, Medipol Mega University Hospital Istanbul, Istanbul, Turkey
| | - Bakir Kudić
- Faculty of Medicine, University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Salko Zahirović
- Department of Neurosurgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Almir Džurlić
- Department of Neurosurgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Adi Ahmetspahić
- Department of Neurosurgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Mirza Pojskić
- Department of Neurosurgery, Philipps University Marburg, University Hospital Marburg, Germany
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Iqbal U, Arsal SA, Kumar A. Letter to the editor: Acute-to-chronic subdural hematoma: radiographic and clinical progression from acute subdural hematoma. Neurosurg Rev 2024; 47:271. [PMID: 38866940 DOI: 10.1007/s10143-024-02512-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 06/03/2024] [Accepted: 06/08/2024] [Indexed: 06/14/2024]
Affiliation(s)
- Umer Iqbal
- Shaheed Mohtarma Benazir Bhutto Medical College, Lyari Hospital Rd, Rangiwara Karachi, Karachi, 75100, Pakistan.
| | - Syed Ali Arsal
- Shaheed Mohtarma Benazir Bhutto Medical College, Lyari Hospital Rd, Rangiwara Karachi, Karachi, 75100, Pakistan
| | - Aashish Kumar
- Shaheed Mohtarma Benazir Bhutto Medical College, Lyari Hospital Rd, Rangiwara Karachi, Karachi, 75100, Pakistan
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Sağıroğlu S, Şirin C, Turgut AÇ, Tomruk C, Tuzcu A, Ertekin E, Uyanıkgil Y, Turgut M. Investigation of the Efficacy of Bevacizumab Treatment in An Experimental Rat Model of Chronic Subdural Hematoma. World Neurosurg 2024:S1878-8750(24)00994-X. [PMID: 38871290 DOI: 10.1016/j.wneu.2024.06.036] [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: 06/06/2024] [Accepted: 06/07/2024] [Indexed: 06/15/2024]
Abstract
INTRODUCTION Chronic subdural hematoma (cSDH), a condition that develops over time, is characterized by inflammation, angiogenesis, and membrane development. As the population's average age increases, the incidence of cSDH is expected to grow. While surgery is the primary treatment technique, medicinal therapy options are being explored for high-risk patients. Currently, the most effective therapy combination is dexamethasone (Dex) and atorvastatin (Ato); however, it is associated with an increased risk of mortality. This study explored the effects of bevacizumab (Bev), a vascular endothelial growth factor antagonist, on cSDH. MATERIALS AND METHODS Ninety-five rats were divided into four groups (n = 18): sham, control hematoma, Dex-Ato, and Bev. Two separate autologous blood injections into the subdural space were used as the model. Weight was monitored for all rats to assess changes in their overall health. The control group was given i.p. saline, the Dex-Ato treatment was given by gavage, and the Bev treatment was given i.p. On seventh, 14th and 21st days six rats from each group were sacrificed and analyzed, while 23 rats were excluded from the experiment. RESULTS The maximum immunological response to cSDH was observed on day 14. Hematoma volume decreased over time in all groups. Dex-Ato and Bev were both found effective, while Dex-Ato caused weight loss. CONCLUSION Bev had similar effects to the Dex-Ato group and was well tolerated by rats. Given that cSDH is a disease of the elderly and vulnerable populations, Bev may be a viable alternative that can shed light on the disease's etiology for future research.
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Affiliation(s)
- Sinan Sağıroğlu
- Department of Neurosurgery, Aydın Adnan Menderes University Faculty of Medicine, Aydın, Turkey
| | - Cansın Şirin
- Department of Histology and Embryology, Ege University Faculty of Medicine, İzmir, Turkey
| | - Ali Çağlar Turgut
- Department of Radiology, Ege University Faculty of Medicine, İzmir, Turkey; Department of Histology and Embryology, Aydın Adnan Menderes University Health Sciences Institute, Aydın, Turkey
| | - Canberk Tomruk
- Department of Histology and Embryology, Samsun Education and Research Hospital, Samsun, Turkey
| | - Ayça Tuzcu
- Department of Biochemistry, Aydın Adnan Menderes University Faculty of Medicine, Aydın, Turkey
| | - Ersen Ertekin
- Department of Radiology, Hitit University Faculty of Medicine, Çorum, Turkey
| | - Yiğit Uyanıkgil
- Department of Histology and Embryology, Ege University Faculty of Medicine, İzmir, Turkey; Department of Stem Cell, Ege University, Health Science Institute, İzmir, Turkey; Cord Blood, Cell and Tissue Research and Application Centre, Ege University, İzmir, Turkey
| | - Mehmet Turgut
- Department of Neurosurgery, Aydın Adnan Menderes University Faculty of Medicine, Aydın, Turkey; Department of Histology and Embryology, Aydın Adnan Menderes University Health Sciences Institute, Aydın, Turkey.
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Mathew C, Wong TGL, Leong RWL. Local anesthesia versus general anesthesia for surgical drainage of chronic subdural hematoma: a systematic review and meta-analysis. Can J Anaesth 2024; 71:870-882. [PMID: 38418762 DOI: 10.1007/s12630-024-02703-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 11/20/2023] [Accepted: 11/21/2023] [Indexed: 03/02/2024] Open
Abstract
PURPOSE The optimal anesthetic technique for surgical drainage of chronic subdural hematoma (CSDH) is still uncertain. We performed this systematic review and meta-analysis to determine if local anesthesia with or without sedation (LA) or general anesthesia (GA) results in better outcomes for surgical drainage of CSDH. METHODS We searched PubMed, EMBASE, Scopus, Cochrane Central Register of Controlled Trials and ClinicalTrials.gov for randomized controlled trials (RCTs) and prospective or retrospective studies that compared GA vs LA for adult patients undergoing surgical drainage of CSDH and reported at least one outcome of interest. Primary outcomes of interest included total duration of surgery, recurrence rate, and length of hospital stay (LOS). Secondary outcomes included intraoperative adverse events, postoperative complications, and postoperative mortality. RESULTS Eight studies (1,542 patients; 926 LA; 616 GA) were included-two were RCTs and six were observational studies. Pooling the estimates of all available studies, we found that LA was associated with a decreased mean LOS by about two days (95% confidence interval [CI], -3.47 to -0.77; P = 0.01; low certainty of evidence) as well as a lower risk of postoperative complications (odds ratio, 0.31; 95% CI, 0.17 to 0.58; P = 0.004; very low certainty of evidence). There was no significant difference in terms of duration of surgery, recurrence rate, intraoperative adverse events, or mortality. The quality of the observational studies was poor to fair, largely because of heterogeneity among the studies. Among the RCTs, one had a low risk of bias and one was deemed to be at high risk of bias. CONCLUSIONS Local anesthesia with/without sedation for surgical drainage of CSDH may be associated with a shorter LOS, and lower postoperative complications. As most of our included studies were observational in nature, our results should be interpreted as summaries of unadjusted group comparisons. In view of the low certainty of evidence, higher quality evidence is required to corroborate these findings. STUDY REGISTRATION PROSPERO (CRD42022333388); first submitted 1 June 2022.
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Affiliation(s)
- Christopher Mathew
- Division of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore.
| | - Theodore G L Wong
- Division of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Rachel W L Leong
- Division of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
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Heinonen A, Rauhala M, Isokuortti H, Raj R, Kataja A, Nikula M, Öhman J, Iverson GL, Luoto T. Incidence of surgically treated chronic subdural hematoma after head injury with normal initial computed tomography. Acta Neurochir (Wien) 2024; 166:144. [PMID: 38514587 PMCID: PMC10957655 DOI: 10.1007/s00701-024-06040-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 03/12/2024] [Indexed: 03/23/2024]
Abstract
PURPOSE The objective was to determine the incidence of surgically treated chronic subdural hematoma (cSDH) within six months after head trauma in a consecutive series of head injury patients with a normal initial computed tomography (CT). METHODS A total of 1941 adult patients with head injuries who underwent head CT within 48 h after injury and were treated at the Tampere University Hospital's emergency department were retrospectively evaluated from medical records (median age = 59 years, IQR = 39-79 years, males = 58%, patients using antithrombotic medication = 26%). Patients with no signs of acute traumatic intracranial pathology or any type of subdural collection on initial head CT were regarded as CT negative (n = 1573, 81%). RESULTS Two (n = 2) of the 1573 CT negative patients received surgical treatment for cSDH. Consequently, the incidence of surgically treated cSDH after a normal initial head CT during a six-month follow-up was 0.13%. Both patients sustained mild traumatic brain injuries initially. One of the two patients was on antithrombotic medication (warfarin) at the time of trauma, hence incidence of surgically treated cSDH among patients with antithrombotic medication in CT negative patients (n = 376, 23.9%) was 0.27%. Additionally, within CT negative patients, one subdural hygroma was operated shortly after trauma. CONCLUSION The extremely low incidence of surgically treated cSDH after a normal initial head CT, even in patients on antithrombotic medication, supports the notion that routine follow-up imaging after an initial normal head CT is not indicated to exclude the development of cSDH. Additionally, our findings support the concept of cSDH not being a purely head trauma-related disease.
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Affiliation(s)
- Aaro Heinonen
- The Faculty of Medicine and Health Technology, Tampere University, Arvo Ylpön katu 34, 33520, Tampere, Finland.
| | - Minna Rauhala
- Department of Neurosurgery, Tampere University Hospital, Tampere, Finland
| | - Harri Isokuortti
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Rahul Raj
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Anneli Kataja
- Department of Radiology, Medical Imaging Centre, Tampere University Hospital, Tampere, Finland
| | - Milaja Nikula
- The Faculty of Medicine and Health Technology, Tampere University, Arvo Ylpön katu 34, 33520, Tampere, Finland
| | - Juha Öhman
- Department of Neurosurgery, Tampere University Hospital, Tampere, Finland
| | - Grant L Iverson
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and the Schoen Adams Research Institute at Spaulding Rehabilitation, Charlestown, MA, USA
| | - Teemu Luoto
- The Faculty of Medicine and Health Technology, Tampere University, Arvo Ylpön katu 34, 33520, Tampere, Finland
- Department of Neurosurgery, Tampere University Hospital, Tampere, Finland
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Staartjes VE, Spinello A, Schwendinger N, Germans MR, Serra C, Regli L. Safety and Effectiveness of an Enhanced Recovery Protocol in Patients Undergoing Burr Hole Evacuation for Chronic Subdural Hematoma. Neurosurgery 2024; 95:00006123-990000000-01042. [PMID: 38323829 PMCID: PMC11155564 DOI: 10.1227/neu.0000000000002849] [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: 10/02/2023] [Accepted: 12/19/2023] [Indexed: 02/08/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Enhanced recovery programs may be especially useful in patients with chronic subdural hematoma or hygroma (cSDH), who frequently exhibit frailty and multimorbidity. We aim to evaluate the real-world safety and effectiveness of an enhanced recovery protocol in this population. METHODS From a prospective registry, burr hole evacuations for cSDH carried out under the protocol (including early thromboprophylaxis, no flat bed rest, early mobilization without drain clamping, and early resumption of antithrombotic medication) were extracted, along with those procedures carried out within the past year before protocol change. Propensity score-based matching was carried out. A range of clinical and imaging outcomes were analyzed, including modified Rankin Scale as effectiveness and Clavien-Dindo adverse event grading as safety primary end points. RESULTS Per group, 91 procedures were analyzed. At discharge, there was no significant difference in the modified Rankin Scale among the standard and enhanced recovery groups (1 [1; 2] vs 1 [1; 3], P = .552), or in Clavien-Dindo adverse event grading classifications of adverse events (P = .282) or occurrence of any adverse events (15.4% vs 20.9%, P = .442). There were no significant differences in time to drain removal (2.00 [2.00; 2.00] vs 2.00 [1.25; 2.00] days, P = .058), time from procedure to discharge (4.0 [3.0; 6.0] vs 4.0 [3.0; 6.0] days, P = .201), or total hospital length of stay (6.0 [5.0; 9.0] vs 5.0 [4.0; 8.0] days, P = .113). All-cause mortality was similar in both groups (8.8% vs 4.4%, P = .289), as was discharge disposition (P = .192). Other clinical and imaging outcomes were similar too (all P > .05). CONCLUSION In a matched cohort study comparing perioperative standard of care with a novel enhanced recovery protocol focusing on evidence-based drainage, mobilization, and thromboprophylaxis regimens as well as changes to the standardized reuptake of oral anticoagulants and antiaggregants, no differences in safety or effectiveness were observed after burr hole evacuation of cSDH.
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Affiliation(s)
- Victor E. Staartjes
- Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Antonio Spinello
- Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Nina Schwendinger
- Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Menno R. Germans
- Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Carlo Serra
- Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Luca Regli
- Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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Liu T, Zhao Z, Huang J, Zhu X, Chen W, Lin K, Yu Y, Li Z, Fan Y, Liu M, Nie M, Liu X, Gao C, Quan W, Qian Y, Wu C, Yuan J, Wu D, Lv C, Dong S, Mi L, Tian Y, Tian Y, Zhang J, Jiang R. Multimodality management for chronic subdural hematoma in China: protocol and characteristics of an ambidirectional, nationwide, multicenter registry study. Chin Neurosurg J 2024; 10:4. [PMID: 38273380 PMCID: PMC10809648 DOI: 10.1186/s41016-024-00356-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 01/12/2024] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND Despite its prevalence, there is ongoing debate regarding the optimal management strategy for chronic subdural hematoma (CSDH), reflecting the variability in clinical presentation and treatment outcomes. This ambidirectional, nationwide, multicenter registry study aims to assess the efficacy and safety of multimodality treatment approaches for CSDH in the Chinese population. METHODS/DESIGN A multicenter cohort of CSDH patients from 59 participating hospitals in mainland China was enrolled in this study. The treatment modalities encompassed a range of options and baseline demographics, clinical characteristics, radiographic findings, and surgical techniques were documented. Clinical outcomes, including hematoma resolution, recurrence rates, neurological status, and complications, were assessed at regular intervals during treatment, 3 months, 6 months, 1 year, and 2 years follow-up. RESULT Between March 2022 and August 2023, a comprehensive cohort comprising 2173 individuals who met the criterion was assembled across 59 participating clinical sites. Of those patients, 81.1% were male, exhibiting an average age of 70.12 ± 14.53 years. A historical record of trauma was documented in 48.0% of cases, while headache constituted the predominant clinical presentation in 58.1% of patients. The foremost surgical modality employed was the burr hole (61.3%), with conservative management accounting for 25.6% of cases. Notably, a favorable clinical prognosis was observed in 88.9% of CSDH patients at 3 months, and the recurrence rate was found to be 2.4%. CONCLUSION This registry study provides critical insights into the multimodality treatment of CSDH in China, offering a foundation for advancing clinical practices, optimizing patient management, and ultimately, improving the quality of life for individuals suffering from this challenging neurosurgical condition. TRIAL REGISTRATION ChiCTR2200057179.
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Affiliation(s)
- Tao Liu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Ministry of Education, Tianjin Neurological Institute, Key Laboratory of Post Neuro-injury Neuro-repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Tianjin, China
| | - Zhihao Zhao
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Ministry of Education, Tianjin Neurological Institute, Key Laboratory of Post Neuro-injury Neuro-repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Tianjin, China
| | - Jinhao Huang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Ministry of Education, Tianjin Neurological Institute, Key Laboratory of Post Neuro-injury Neuro-repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Tianjin, China
| | - Xide Zhu
- Department of Neurosurgery, Linyi People's Hospital, Shandong, China
| | - Weiliang Chen
- Department of Neurosurgery, Haining People's Hospital, Zhejiang, China
| | - Kun Lin
- Department of Neurosurgery, Fujian Provincial Hospital, Fujian, China
| | - Yunhu Yu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Ministry of Education, Tianjin Neurological Institute, Key Laboratory of Post Neuro-injury Neuro-repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Tianjin, China
- Department of Clinical Research Center for Neurological Disease, the People's Hospital of HongHuaGang District of ZunYi, Guizhou, China
| | - Zhanying Li
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Ministry of Education, Tianjin Neurological Institute, Key Laboratory of Post Neuro-injury Neuro-repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Tianjin, China
- Department of Neurosurgery, Kailuan General Hospital, Hebei, China
| | - Yibing Fan
- Department of Neurosurgery, Tianjin First Central Hospital, Tianjin, China
| | - Mingqi Liu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Ministry of Education, Tianjin Neurological Institute, Key Laboratory of Post Neuro-injury Neuro-repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Tianjin, China
| | - Meng Nie
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Ministry of Education, Tianjin Neurological Institute, Key Laboratory of Post Neuro-injury Neuro-repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Tianjin, China
| | - Xuanhui Liu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Ministry of Education, Tianjin Neurological Institute, Key Laboratory of Post Neuro-injury Neuro-repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Tianjin, China
| | - Chuang Gao
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Ministry of Education, Tianjin Neurological Institute, Key Laboratory of Post Neuro-injury Neuro-repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Tianjin, China
| | - Wei Quan
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Ministry of Education, Tianjin Neurological Institute, Key Laboratory of Post Neuro-injury Neuro-repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Tianjin, China
| | - Yu Qian
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Ministry of Education, Tianjin Neurological Institute, Key Laboratory of Post Neuro-injury Neuro-repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Tianjin, China
| | - Chenrui Wu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Ministry of Education, Tianjin Neurological Institute, Key Laboratory of Post Neuro-injury Neuro-repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Tianjin, China
| | - Jiangyuan Yuan
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Ministry of Education, Tianjin Neurological Institute, Key Laboratory of Post Neuro-injury Neuro-repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Tianjin, China
| | - Di Wu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Ministry of Education, Tianjin Neurological Institute, Key Laboratory of Post Neuro-injury Neuro-repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Tianjin, China
| | - Chuanxiang Lv
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, China
| | - Shiying Dong
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Ministry of Education, Tianjin Neurological Institute, Key Laboratory of Post Neuro-injury Neuro-repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Tianjin, China
| | - Liang Mi
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Ministry of Education, Tianjin Neurological Institute, Key Laboratory of Post Neuro-injury Neuro-repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Tianjin, China
| | - Yu Tian
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Ministry of Education, Tianjin Neurological Institute, Key Laboratory of Post Neuro-injury Neuro-repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Tianjin, China
| | - Ye Tian
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.
- Ministry of Education, Tianjin Neurological Institute, Key Laboratory of Post Neuro-injury Neuro-repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Tianjin, China.
| | - Jianning Zhang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.
- Ministry of Education, Tianjin Neurological Institute, Key Laboratory of Post Neuro-injury Neuro-repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Tianjin, China.
| | - Rongcai Jiang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.
- Ministry of Education, Tianjin Neurological Institute, Key Laboratory of Post Neuro-injury Neuro-repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Tianjin, China.
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11
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Sioutas GS, Sweid A, Chen CJ, Becerril-Gaitan A, Al Saiegh F, El Naamani K, Abbas R, Amllay A, Birkenstock L, Cain RE, Ruiz RL, Buxbaum M, Nauheim DO, Renslo B, Bassig J, Gooch MR, Herial NA, Jabbour P, Rosenwasser RH, Tjoumakaris SI. Surgical evacuation for chronic subdural hematoma: Predictors of reoperation and functional outcomes. World Neurosurg X 2024; 21:100246. [PMID: 38054079 PMCID: PMC10694339 DOI: 10.1016/j.wnsx.2023.100246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 10/24/2023] [Indexed: 12/07/2023] Open
Abstract
Background Although chronic subdural hematoma (CSDH) incidence has increased, there is limited evidence to guide patient management after surgical evacuation. Objective To identify predictors of reoperation and functional outcome after CSDH surgical evacuation. Methods We identified all patients with CSDH between 2010 and 2018. Clinical and radiographic variables were collected from the medical records. Outcomes included reoperation within 90 days and poor (3-6) modified Rankin Scale score at 3 months. Results We identified 461 surgically treated CSDH cases (396 patients). The mean age was 70.1 years, 29.7 % were females, 298 (64.6 %) underwent burr hole evacuation, 152 (33.0 %) craniotomy, and 11 (2.4 %) craniectomy. Reoperation rate within 90 days was 12.6 %, whereas 24.2 % of cases had a poor functional status at 3 months. Only female sex was associated with reoperation within 90 days (OR = 2.09, 95 % CI: 1.17-3.75, P = 0.013). AMS on admission (OR = 5.19, 95 % CI: 2.15-12.52, P < 0.001) and female sex (OR = 3.90, 95 % CI: 1.57-9.70, P = 0.003) were independent predictors of poor functional outcome at 3 months. Conclusion Careful management of patients with the above predictive factors may reduce CSDH reoperation and improve long-term functional outcomes. However, larger randomized studies are necessary to assess long-term prognosis after surgical evacuation.
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Affiliation(s)
- Georgios S. Sioutas
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Ahmad Sweid
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Ching-Jen Chen
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
- Department of Neurosurgery, The University of Texas Health Science Center, Houston, TX, USA
| | - Andrea Becerril-Gaitan
- Department of Neurosurgery, The University of Texas Health Science Center, Houston, TX, USA
| | - Fadi Al Saiegh
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Rawad Abbas
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Abdelaziz Amllay
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Lyena Birkenstock
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Rachel E. Cain
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Ramon L. Ruiz
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Michael Buxbaum
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - David O. Nauheim
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Bryan Renslo
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Jonathan Bassig
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - M. Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Nabeel A. Herial
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Robert H. Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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12
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Wu Z, Wang H, Zhao J, Wang C, Liu H, Wang C, Li A, Hu J. Preoperative Fibrinogen Levels and Function as Predictive Factors for Acute Bleeding in the Hematoma Cavity After Burr Hole Drainage in Patients with CSDH. World Neurosurg 2023; 180:e364-e375. [PMID: 37769840 DOI: 10.1016/j.wneu.2023.09.072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 09/18/2023] [Indexed: 10/03/2023]
Abstract
OBJECTIVE Burr hole drainage (BHD) is the primary surgical intervention for managing chronic subdural hematoma (CSDH). However, it can lead to postoperative complications such as acute bleeding within the hematoma cavity and hematoma recurrence. The objective of this study is to identify the risk factors for these complications and develop a predictive model for acute hematoma cavity bleeding after BHD in patients with CSDH. METHODS This study presents a retrospective cohort investigation conducted at a single center. The clinical dataset of 308 CSDH patients who underwent BHD at a hospital from 2016 to 2022 was analyzed to develop and assess a prognostic model. RESULTS The nonbleeding group exhibited a significant correlation between fibrinogen (FIB) and thrombin time (TT), whereas no correlation was observed in the bleeding group. Notably, both FIB and TT were identified as risk factors for postoperative acute bleeding within the hematoma cavity. We developed a prognostic model to predict the occurrence of postoperative acute bleeding within the hematoma cavity after BHD in patients with CSDH. The model incorporated FIB, TT, coronary artery disease, and Glasgow Coma Scale scores. The model exhibited good discrimination (area under the curve: 0.725) and calibration (Hosmer-Leeshawn goodness of fit test: P > 0.1). Furthermore, decision curve analysis demonstrated the potential clinical benefit of implementing this prediction model. CONCLUSIONS The predictive model developed in this study can forecast the risk of postoperative acute bleeding within the hematoma cavity, thus aiding clinicians in selecting the optimal treatment approach for patients with CSDH.
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Affiliation(s)
- Zejun Wu
- Department of Neurosurgery, Taihe Hospital, Jinzhou Medical University Union Training Base, Shiyan, China; Department of Neurosurgery, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Hui Wang
- Department of Neurosurgery, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Junshuang Zhao
- Department of Neurosurgery, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Chaobin Wang
- Department of Neurosurgery, Taihe Hospital, Jinzhou Medical University Union Training Base, Shiyan, China
| | - Haodong Liu
- The First Clinical College, Hubei University of Medicine, Shiyan, China
| | - Chaojia Wang
- Department of Neurosurgery, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Anrong Li
- Department of Neurosurgery, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Juntao Hu
- Department of Neurosurgery, Taihe Hospital, Hubei University of Medicine, Shiyan, China; Hubei KeyLaboratory of Embryonic Stem Cell Research, Tai-He Hospital, Hubei University of Medicine, Shiyan, China.
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13
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Matsubara M, Yagi K, Minami Y, Kanda E, Sunada Y, Tao Y, Takai H, Shikata E, Hirai S, Matsubara S, Uno M. Preoperative elevated eosinophils in peripheral blood for prediction of postoperative recurrence of chronic subdural hematoma. J Neurosurg 2023; 139:708-713. [PMID: 36640094 DOI: 10.3171/2022.12.jns222432] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 12/07/2022] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Chronic subdural hematoma (CSDH) is a common neurological disease with a significant postoperative recurrence rate. There are numerous reported studies of the development of CSDH. In recent years, fibrinolysis, angiogenesis, and inflammation have all been identified as relevant factors in the development of CSDH. While several authors have reported risk factors associated with CSDH recurrence, differential blood count of leukocytes has not yet been discussed. Therefore, in this study the authors aimed to retrospectively investigate the association between differential blood leukocyte count and the rate of CSDH recurrence. METHODS The authors retrospectively reviewed 476 patients with 529 CSDHs who underwent surgery at a single institution between January 2011 and December 2021. After exclusion of patients who had not undergone a differential blood test of leukocytes preoperatively, CSDHs in 517 cerebral hemispheres of 466 patients were included in the study. Peripheral blood eosinophil counts ≥ 100/µL were considered eosinophil rich. RESULTS CSDHs in 494 cerebral hemispheres of 445 patients were followed up postoperatively for at least 3 months or until resolution indicated by CSDH disappearance. Postoperative recurrence of CSDH was observed in 46 cerebral hemispheres (9.3%). Among the preoperative differential blood counts of all leukocytes, eosinophils alone were significantly associated with CSDH recurrence (median [IQR] 76/µL [30-155/µL] vs 119/µL [39-217/µL]; p = 0.03). Multivariable regression analysis showed thrombocytopenia (adjusted OR [aOR] 5.23, 95% CI 1.85-14.79; p = 0.002), use of anticoagulant drugs (aOR 2.51, 95% CI 1.17-5.38; p = 0.02), hematoma volume (10 mL per increase) (aOR 1.08, 95% CI 1.00-1.16; p = 0.04), and eosinophil-rich peripheral blood (aOR 2.22, 95% CI 1.17-4.23; p = 0.02) were all independent predictors for CSDH recurrence. CONCLUSIONS This study showed that preoperative peripheral blood eosinophil count was an independent risk factor for CSDH recurrence. Therefore, patients with CSDH who have elevated eosinophils preoperatively in peripheral blood require careful follow-up.
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Affiliation(s)
| | | | | | - Eiichiro Kanda
- 2Medical Science, Kawasaki Medical School, Kurashiki, Okayama, Japan
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14
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Lee G, Jang Y, Whang K, Cho S, Kim J, Kim B, Choi J. Factors Associated With Short-Term Outcomes of Burr-Hole Craniostomy Associated With Brain Re-Expansion and Subdural Hematoma Shrinkage for Chronic Subdural Hematoma. Korean J Neurotrauma 2023; 19:324-332. [PMID: 37840618 PMCID: PMC10567527 DOI: 10.13004/kjnt.2023.19.e51] [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: 06/15/2023] [Revised: 09/08/2023] [Accepted: 09/08/2023] [Indexed: 10/17/2023] Open
Abstract
Objective Chronic subdural hematoma (CSDH) is a commonly encountered neurosurgical pathology that frequently requires surgical intervention. With an increasingly aging demographic, more older people and patients with comorbidities will present with symptomatic CSDH. This study evaluated clinical and laboratory factors affecting the short-term outcomes of CSDH after surgical intervention. Methods We retrospectively analyzed 170 patients who underwent burr-hole trephination for CSDH in a single institution from January 2019 to December 2021. All patients were examined for risk factors and evaluated for hematoma thickness change and midline shifting on brain computed tomography (CT) scans at 3 days after burr-hole trephination. Results This consecutive series of patients included 114 males (67.1%) and 56 females (32.9%); mean age 72.4±12.5 years. Renal disease (p=0.044) and prior intracranial hemorrhage (p=0.004) were clinical factors associated with poorer prognosis. A statistically significant association was found between initial laboratory findings, including high creatine kinase (p=0.025) and low platelet (p=0.036) levels, and CT findings 3 days postoperatively. The 3-day mean arterial pressure and postoperative ambulation were not significantly associated with outcomes. Conclusion Burr-hole craniostomy is an effective surgical procedure for initial CSDH. However, patients with a history intracranial hemorrhage and abnormal laboratory findings, such as low platelet levels, who underwent burr-hole trephination had poor short-term outcomes. Therefore, these patients should be carefully monitored.
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Affiliation(s)
- Gyubin Lee
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Yeongyu Jang
- Department of Neurosurgery, Konkuk University Chungju Hospital, Chungju, Korea
| | - Kum Whang
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Sungmin Cho
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jongyeon Kim
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Byeongoh Kim
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jongwook Choi
- Department of Neurosurgery, Konkuk University Chungju Hospital, Chungju, Korea
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15
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Beucler N. Chronic subdural hematoma: time for an evidence-based surgical treatment. Acta Neurochir (Wien) 2023; 165:2361-2363. [PMID: 37340222 DOI: 10.1007/s00701-023-05677-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 02/14/2023] [Indexed: 06/22/2023]
Affiliation(s)
- Nathan Beucler
- Neurosurgery Department, Sainte-Anne Military Teaching Hospital, 2 boulevard Sainte-Anne, 83800 Cedex 9, Toulon, France.
- Ecole du Val-de-Grâce, French Military Health Service Academy, 1 place Alphonse Laveran, 75230 Cedex 5, Paris, France.
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16
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Chen C, Xiong Y, Huang X, Guo X, Kang X, Zhou J, Pan Z, Zheng H, Zheng S, Wang L, Hu W, Zhuang L, Zheng F. Subperiosteal/subgaleal drainage vs. subdural drainage for chronic subdural hematoma: A meta-analysis of postoperative outcomes. PLoS One 2023; 18:e0288872. [PMID: 37527264 PMCID: PMC10393133 DOI: 10.1371/journal.pone.0288872] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 07/05/2023] [Indexed: 08/03/2023] Open
Abstract
BACKGROUND Chronic subdural hematoma (CSDH) is commonly treated via surgical removal of the hematoma, placement of a routine indwelling drainage tube, and continuous drainage to ensure that the blood does not re-aggregate following removal. However, the optimal location for placement of the drainage tube remains to be determined. OBJECTIVES To aid in establishing a reference for selecting the optimal method, we compared the effects of different drainage tube placements on CSDH prognosis via a systematic review and meta-analysis of previous clinical studies. DATA SOURCES PubMed, Embase, and Cochrane databases. STUDY ELIGIBILITY CRITERIA We searched for clinical studies comparing the outcomes of subperiosteal/subgaleal drainage (SPGD) and subdural drainage (SDD) for CSDH published in English prior to April 1, 2022. PARTICIPANTS The final analysis included 15 studies involving 4,318 patients. RESULTS Our analysis of the pooled results revealed no significant differences in recurrence rate between the SDD and SPGD groups. We also observed no significant differences in mortality or rates of postoperative complications (infection, pneumocephalus, or epilepsy) between the SDD and SPGD groups. CONCLUSIONS These results suggest that the choice of SDD vs. SPGD has no significant effect on CSDH prognosis, highlighting SPGD as an alternative treatment option for CSDH.
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Affiliation(s)
- Chunhui Chen
- Department of Neurosurgery, the Second Affiliated Hospital, Fujian Medical University, Quanzhou, Fujian Province, China
| | - Yu Xiong
- Department of Neurosurgery, the Second Affiliated Hospital, Fujian Medical University, Quanzhou, Fujian Province, China
| | - Xinyue Huang
- Department of Neurosurgery, the Second Affiliated Hospital, Fujian Medical University, Quanzhou, Fujian Province, China
| | - Xiumei Guo
- Department of Neurosurgery, the Second Affiliated Hospital, Fujian Medical University, Quanzhou, Fujian Province, China
- Department of Neurology, the Second Affiliated Hospital, Fujian Medical University, Quanzhou, Fujian Province, China
| | - Xiaodong Kang
- Department of Neurosurgery, the Second Affiliated Hospital, Fujian Medical University, Quanzhou, Fujian Province, China
| | - Jianfeng Zhou
- Department of Neurosurgery, the Second Affiliated Hospital, Fujian Medical University, Quanzhou, Fujian Province, China
| | - Zhigang Pan
- Department of Neurosurgery, the Second Affiliated Hospital, Fujian Medical University, Quanzhou, Fujian Province, China
| | - Hanlin Zheng
- Department of Neurosurgery, the Second Affiliated Hospital, Fujian Medical University, Quanzhou, Fujian Province, China
| | - Shuni Zheng
- Division of Public Management, the Second Affiliated Hospital, Fujian Medical University, Quanzhou, Fujian Province, China
| | - Linxing Wang
- Department of Neurology, the Second Affiliated Hospital, Fujian Medical University, Quanzhou, Fujian Province, China
| | - Weipeng Hu
- Department of Neurosurgery, the Second Affiliated Hospital, Fujian Medical University, Quanzhou, Fujian Province, China
| | - Liming Zhuang
- Department of Pharmacy, the Second Affiliated Hospital, Fujian Medical University, Quanzhou, Fujian Province, China
| | - Feng Zheng
- Department of Neurosurgery, the Second Affiliated Hospital, Fujian Medical University, Quanzhou, Fujian Province, China
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17
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Cordeiro JG, Assumpcao de Monaco B, Benveniste R, Alkhachroum A, Krueger EM, O'Phelan K, Jagid JR. Chronic subdural hematoma drainage using anti-thrombotic catheter technique. World Neurosurg X 2023; 19:100215. [PMID: 37304158 PMCID: PMC10248548 DOI: 10.1016/j.wnsx.2023.100215] [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: 08/11/2022] [Revised: 05/08/2023] [Accepted: 05/10/2023] [Indexed: 06/13/2023] Open
Abstract
Background Burr hole evacuation is a well-established treatment for symptomatic cases with chronic subdural hematoma (cSDH). Routinely postoperative catheter is left in the subdural space to drain the residual blood. Drainage obstruction is commonly seen, and it can be related to suboptimal treatment. Methods Two groups of patients submitted to cSDH surgery were evaluated in a retrospective non-randomized trial, one group that had conventional subdural drainage (CD group, n = 20) and another group that used an anti-thrombotic catheter (AT group, n = 14). We compared the obstruction rate, amount of drainage and complications. Statistical analyses were done using SPSS (v.28.0). Results For AT and CD groups respectively (median ± IQR), the age was 68.23 ± 26.0 and 70.94 ± 21.5 (p > 0.05); preoperative hematoma width was 18.3 ± 11.0 mm and 20.7 ± 11.7 mm and midline shift was 13.0 ± 9.2 and 5.2 ± 8.0 mm (p = 0.49). Postoperative hematoma width was 12.7 ± 9.2 mm and 10.8 ± 9.0 mm (p < 0.001 intra-groups compared to preoperative) and MLS was 5.2 ± 8.0 mm and 1.5 ± 4.3 mm (p < 0.05 intra-groups). There were no complications related to the procedure including infection, bleed worsening and edema. No proximal obstruction was observed on the AT, but 8/20 (40%) presented proximal obstruction on the CD group (p = 0.006). Daily drainage rates and length of drainage were higher in AT compared to CD: 4.0 ± 1.25 days vs. 3.0 ± 1.0 days (p < 0.001) and 69.86 ± 106.54 vs. 35.00 ± 59.67 mL/day (p = 0.074). Symptomatic recurrence demanding surgery occurred in two patients of CD group (10%) and none in AT group (p = 0.230), after adjusting for MMA embolization, there was still no difference between groups (p = 0.121). Conclusion The anti-thrombotic catheter for cSDH drainage presented significant less proximal obstruction than the conventional one and higher daily drainage rates. Both methods demonstrated to safe and effective for draining cSDH.
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Affiliation(s)
| | - Bernardo Assumpcao de Monaco
- Neurosurgery Department, University of Miami, Miami, FL, USA
- Neurosurgery Department, University of Sao Paulo Medical School, Sao Paulo, SP, Brazil
| | | | - Ayham Alkhachroum
- Neurocritical Care Division, Neurology Department, University of Miami, Miami, FL, USA
| | - Evan M. Krueger
- Neurosurgery Department, University of Miami, Miami, FL, USA
| | - Kristine O'Phelan
- Neurocritical Care Division, Neurology Department, University of Miami, Miami, FL, USA
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18
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Zhu B, Ou Y, Guo X, Liu W, Wu L. A low prognostic nutritional index is associated with chronic subdural hematoma recurrence. Neurosurg Rev 2023; 46:139. [PMID: 37296275 DOI: 10.1007/s10143-023-02042-z] [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: 02/26/2023] [Revised: 04/28/2023] [Accepted: 05/27/2023] [Indexed: 06/12/2023]
Abstract
Chronic subdural hematoma (CSDH) is a common neurosurgical condition. Inflammation has been found to play an essential role in the formation of CSDHs, and the prognostic nutritional index (PNI), a nutritional and inflammatory baseline marker, plays a role in predicting the prognosis of many diseases. We aimed to identify the relationship between PNI and CSDH recurrence. This study retrospectively analyzed 261 CSDH patients who underwent burr hole evacuation in Beijing Tiantan Hospital from August 2013 to March 2018. The PNI was calculated as 5 ∗ lymphocyte count (109/L) + serum albumin concentration (g/L), and these markers were obtained from the peripheral blood test on the day of discharge from the hospital. Recurrence was defined as operated hematoma enlargement accompanied by newly emerging neurological disorders. The comparison of baseline characteristics demonstrated that patients with bilateral hematoma and low levels of albumin, lymphocytes, and PNI were more likely to be recurrent. After adjusting for age, sex, and other important variables, decreased PNI levels were associated with an increased risk of CSDH (OR, 0.803, 95% CI: 0.715-0.902, p = 0.001). The addition of PNI to conventional risk factors significantly improved the risk prediction of CSDH (net reclassification index: 71.12%, p = 0.001; integrated discrimination index: 10.94%, p = 0.006). A low PNI level is associated with an increased risk of CSDH recurrence. As an easily obtainable nutritional and inflammatory marker, PNI may play a significant role in predicting the recurrence of CSDH patients.
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Affiliation(s)
- Bingcheng Zhu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yunwei Ou
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xufei Guo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Weiming Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
- China National Clinical Research Center for Neurological Diseases, Beijing, China.
- Neurological Center, People's Hospital of Ningxia Hui Autonomous Region, Yinchuan, China.
| | - Liang Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
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19
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Hegde P, Nayak B, Madishetty A, Perikal PJ, Furtado SV. Validating the Efficacy of Two Burr-Hole Craniostomy over Mini-Craniotomy for Chronic Subdural Hematoma Drainage. Asian J Neurosurg 2023; 18:70-74. [PMID: 37056871 PMCID: PMC10089736 DOI: 10.1055/s-0043-1761232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
Abstract
Background There is an increasing incidence of chronic subdural hematoma due to extended life expectancy and associated trauma and fall risk. This retrospective study evaluates the efficacy of two burr-hole craniotomy over mini-craniotomy.
Methods Sixty-five patients were recruited over 2 years, of which 56 were male and 9 were females. A patient with a chronic subdural hematoma either underwent burr-hole craniostomy or mini-craniotomy for hematoma evacuation. Glasgow coma scale (GCS) and modified Rankin score were used to assess the neurological status and interventional outcome at discharge and follow-up, respectively. A head CT scan was performed at 3 week and 3 month follow-up.
Statistical Analysis Categorical data are presented as frequency and percentage, while non-categorical data are represented as mean ± SD. Statistical significance for difference in outcome between the two groups was analyzed using the chi-square test and p-value less than 0.05 was considered statistically significant.
Results The mean age of patients was 55.6 years. Headache (35 cases), hemiparesis, and altered sensorium were seen in 20 patients, each with the main presenting symptoms. Trauma history was noted in 69.2% of patients. One (3.7%) hematoma recurrence in the burr-hole group and four (8.3%) in the mini-craniotomy group was recorded. The mean operative time was longer in the minicraniotomy group (124.2 min vs. 75.4 min; p < 0.001). A higher incidence of recurrence was noted in the craniotomy group (8.3%) than the burr-hole group (3.7%). No statistical difference in the recurrence rate, duration of hospital stay, GCS at discharge, modified Rankin score between the two study groups at discharge was noted.
Conclusion Two burr-hole craniostomy is a safe and effective surgical option to treat chronic subdural hematoma. It is also validated in patients on anticoagulants and antiplatelet medications with adequate pre-surgical correction of coagulation parameters.
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Roohollahi F, Kankam SB, Shafizadeh M, Khoshnevisan A. A prospective randomized controlled trial of the effect of the number of burr hole on chronic subdural hematoma recurrence: An institutional experience. Clin Neurol Neurosurg 2023; 226:107624. [PMID: 36791590 DOI: 10.1016/j.clineuro.2023.107624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 01/26/2023] [Accepted: 02/05/2023] [Indexed: 02/12/2023]
Abstract
OBJECTIVE The purpose of this study was to compare the effect of single burr hole (SBH) versus double burr hole (DBH) drainage on the recurrence rate of chronic subdural hematoma (CSDH). METHOD Forty-four patients undergoing burr hole craniostomy (BHC) between July 2022 and December 2022 were enrolled in a randomized clinical trial (RCT) comparing SBH to DBH surgeries. The primary endpoint of this study was the recurrence rate of CSDH. Radiological characteristics such as midline shift, thickness, volume, density, type of hematoma, brain atrophy and so on were secondary endpoints. RESULTS Forty-four patients participated in this study. Twenty-two hematomas underwent SBH craniostomy, and the other 22 had DBH craniostomy. The mean age in the SBH and DBH groups were 68.59 ± 7.94 and 69.54 ± 10.58, respectively. In each group, the proportion of males (SBH=16; DBH=15) was higher than that of females (SBH=6; DBH=7). The mean surgery time in the SBH group was significantly less than in the DBH group (p = 0.001). However, the two groups had no statistically significant difference in the CSDH recurrence rate (p = 0.312). CONCLUSION Our findings showed that SBH craniostomy is equally effective as DBH craniostomy at draining hematomas and does not increase the recurrence rate. Contrarily, the SBH craniostomy had a shorter surgical duration than the DBH craniostomy. As a result, we recommend SBH surgeries for all patients, with emphasis on the elderly and those with severe comorbidities, as well as in situations with few surgical facilities and a high patient admission rate.
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Affiliation(s)
- Faramarz Roohollahi
- Department of Neurosurgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Samuel Berchi Kankam
- Department of Neurosurgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran; School of medicine, Tehran University Of Medical Sciences, Tehran, Iran; International Neurosurgery Group, Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Milad Shafizadeh
- Department of Neurosurgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Khoshnevisan
- Department of Neurosurgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran.
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21
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Msheik A, Fares Y, Mohanna M, Aoude A, Shkeir M, Chehade F, Kanj A, Mohanna A. Middle meningeal artery embolisation: The review of a new treatment for chronic subdural hematomas. Surg Neurol Int 2023; 14:66. [PMID: 36895214 PMCID: PMC9990792 DOI: 10.25259/sni_1096_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 02/03/2023] [Indexed: 02/26/2023] Open
Abstract
Background This is a literature review aiming to provide an update about the recent findings related to the efficacy of middle meningeal artery embolization (MMAE) in the treatment of chronic subdural hematomas (cSDHs), comparison with conventional therapy and deduction of the current recommendations and indications. Methods The literature is reviewed using a search through the PubMed index using keywords. Studies are then screened, skimmed, and thoroughly read. 32 studies fulfilled the inclusion criteria and are included in the study. Results Five indications for the application of MMA embolization (MMAE) are deducted from the literature. The usage as a preventive measure after surgical treatment of symptomatic cSDHs in patients with a high risk of recurrence and the usage as a standalone procedure has been the most common reasons for indication of this procedure. Rates of failures for the aforementioned indications have been 6.8% and 3.8%, respectively. Conclusion The safety of MMAE as a procedure is regarded as a general theme in the literature and can be considered for future applications. Usage of this procedure in clinical trials with more patient segregation and timeframe assessment relative to surgical intervention are recommendations of this literature review.
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Affiliation(s)
- Ali Msheik
- Department of Neurological Surgery, Lebanese University, Faculty of Medical Sciences
| | - Youssef Fares
- Department of Neurological Surgery, Neuroscience Research Center, Faculty of Medical Sciences, Lebanese University, Lebanon
| | - Mohammad Mohanna
- Department of Oncology, Cleveland Clinic, Weston, Florida, United States
| | - Ahmad Aoude
- Department of Neurological Surgery, Al Rassoul Al-Azam Hospital
| | - Mohamad Shkeir
- Head of Radiology Department, Zahraa Hospital University Medical Center
| | - Feras Chehade
- Department of Nuclear Medicine Radiobiology Radiopathology, Faculty of Medical Sciences, Lebanese University
| | - Ali Kanj
- Radiology Department, Bahman Hospital, Faculty of Medicine, Lebanese University
| | - Assaad Mohanna
- Head of Department of Radiology, Faculty of Medicine, Lebanese University, Bahman Hospital, Centre Hospitalier Vallee de la Maurienne-France, Beirut, Lebanon
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22
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Yu J, Tang J, Chen M, Ren Q, He J, Tang M, Zhang X, Liu Z, Ding H. Traumatic subdural hygroma and chronic subdural hematoma: A systematic review and meta-analysis. J Clin Neurosci 2023; 107:23-33. [PMID: 36462413 DOI: 10.1016/j.jocn.2022.11.010] [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: 09/10/2022] [Revised: 11/12/2022] [Accepted: 11/19/2022] [Indexed: 12/03/2022]
Abstract
Recently, a relationship between traumatic subdural hygroma (SDG) and chronic subdural hematoma (CSDH) has been proposed. However, the role of traumatic SDG in development of CSDH has not been well characterized. This systematic review aimed to estimate the rate of evolution of traumatic SDG to CSDH, and to identify risk factors associated with traumatic SDG evolution to CSDH. We searched MEDLINE, EMBASE, and Cochrane Library databases from inception to May 26, 2021, using the combination of the terms "subdural hygroma" and "chronic subdural hematoma." Using a random-effects model, we calculated a pooled estimate of rate of evolution of traumatic SDG to CSDH. In addition, we conducted a systematic review of studies of risk factors for traumatic SDG evolution to CSDH. Nineteen studies with 1,335 patients met the inclusion criteria for meta-analysis. The pooled estimate of evolution rate was 25.0 % (95 % CI, 19.3 %-30.7 %; I2 = 85.6 %), with significant heterogeneity among studies (P < 0.01). Age ≥ 60 years was associated independently with traumatic SDG evolution to CSDH, after adjustment for study design using multivariate meta-regression. Risk factors associated with evolution of traumatic SDG to CSDH were radiological characteristics such as thicker SDG and higher SDG CT value. The rate of traumatic SDGs evolution to CSDH is approximately 25 %. Patients aged 60 or older with traumatic SDGs are at increased risk of CSDH development. Thicker SDG and higher SDG CT value, are commonly reported risk factors for traumatic SDG evolution to CSDH. However, higher quality studies are needed.
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Affiliation(s)
- Jinhui Yu
- Department of Neurosurgery, People's Hospital of Yubei District of Chongqing City, Chongqing, China
| | - Jiuning Tang
- Department of Neurosurgery, People's Hospital of Yubei District of Chongqing City, Chongqing, China
| | - Minruo Chen
- Department of Neurosurgery, People's Hospital of Yubei District of Chongqing City, Chongqing, China
| | - Qifu Ren
- Department of Neurosurgery, People's Hospital of Yubei District of Chongqing City, Chongqing, China
| | - Jun He
- Department of Neurosurgery, People's Hospital of Yubei District of Chongqing City, Chongqing, China
| | - Maoyuan Tang
- Department of Neurosurgery, People's Hospital of Yubei District of Chongqing City, Chongqing, China
| | - Xinhai Zhang
- Department of Neurosurgery, People's Hospital of Yubei District of Chongqing City, Chongqing, China
| | - Zhi Liu
- Department of Neurosurgery, People's Hospital of Yubei District of Chongqing City, Chongqing, China
| | - Huaqiang Ding
- Department of Neurosurgery, People's Hospital of Yubei District of Chongqing City, Chongqing, China.
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23
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Hatfield JK, Komisarow JM. Commentary: Randomized Trial Comparing Burr Hole Craniostomy, Minicraniotomy, and Twist Drill Craniostomy for Treatment of Chronic Subdural Hematoma. Neurosurgery 2022; 91:e100-e101. [DOI: 10.1227/neu.0000000000002076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 05/25/2022] [Indexed: 11/19/2022] Open
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