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Brannigan JFM, Gillespie CS, Adegboyega G, Watson M, Lee KS, Mazzoleni A, Goacher E, Mantle O, Omar V, Gamage G, Yanez Touzet A, Mowforth O, Thomas W, Uprichard J, Hutchinson PJ, Stubbs DJ, Davies BM. Impact of antithrombotic agents on outcomes in patients requiring surgery for chronic subdural haematoma: a systematic review and meta-analysis. Br J Neurosurg 2024:1-8. [PMID: 38584489 DOI: 10.1080/02688697.2024.2333399] [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: 12/14/2023] [Accepted: 03/12/2024] [Indexed: 04/09/2024]
Abstract
A chronic subdural haematoma (CSDH) is a collection of aged blood between the dura and the brain, typically treated with surgical evacuation. Many patients with CSDH have comorbidities requiring the use of antithrombotic medications. The optimal management of these medications in the context of CSDH remains unknown, as the risk of recurrence must be carefully weighed against the risk of vaso-occlusive events. To better understand these risks and inform the development of clinical practice guidelines, we conducted a systematic review and meta-analysis. A systematic review was conducted in accordance with the PRISMA guidelines, searching Medline and Embase databases. The study was registered with PROSPERO (CRD42023397061). A total of 44 studies were included, encompassing 1 prospective cohort study and 43 retrospective cohort studies. Pooled odds ratios (ORs) were calculated for CSDH recurrence and vaso-occlusive events in patients taking anticoagulant or antiplatelet medications compared to patients not receiving antithrombotic therapy. GRADE was used to assess the quality of evidence. In patients on anticoagulant therapy at CSDH diagnosis, the pooled OR for CSDH recurrence was 1.41 (95% CI 1.11 to 1.79; I2 = 28%). For patients on antiplatelet therapy, the pooled OR was 1.31 (95% CI 1.08 to 1.58; I2 = 32%). Patients taking antithrombotic medications had a significantly higher risk of vaso-occlusive events, with a pooled OR of 3.74 (95% CI 2.12 to 6.60; I2 = 0%). There was insufficient evidence to assess the impact of time to recommence antithrombotic medication on CSDH outcomes. We found that baseline antithrombotic use is associated with the risk of CSDH recurrence and vaso-occlusive events following surgical evacuation. The evidence base is of low quality, and decisions regarding antithrombotic therapy should be individualised for each patient. Further high-quality, prospective studies or registry-based designs are needed to better inform clinical decision-making and establish evidence-based guidelines.
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Affiliation(s)
- Jamie F M Brannigan
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Conor S Gillespie
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Gideon Adegboyega
- Addenbrookes Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Matthew Watson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | | | - Adele Mazzoleni
- Barts and the London School of Medicine, Queen Mary University of London, London, UK
| | - Edward Goacher
- Sheffield University Teaching Hospitals NHS Trust, Sheffield, UK
| | | | - Vian Omar
- University of Buckingham Medical School, Buckingham, UK
| | - Githmi Gamage
- Royal College of Surgeons of Ireland, Dublin, Republic of Ireland
| | - Alvaro Yanez Touzet
- School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Oliver Mowforth
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Will Thomas
- Department of Haematology, Cambridge University Hospitals NHS Foundation trust, Cambridge, UK
| | - James Uprichard
- Department of Haematology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Daniel J Stubbs
- Department of Haematology, St George's University Hospitals NHS Foundation Trust, London, UK
- Division of Anaesthesia, University of Cambridge Addenbrooke's Hospital Cambridge, Cambridge, UK
| | - Benjamin M Davies
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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Zhang J, Yu L, Wang X, Yu Q, Zhu B, Zhang H, Liu Y, Li H, Zhang A, Wang K, He Y, Wu Q, Fang Y, Sun J, Chen S. The Drainage Dysfunction of Meningeal Lymphatic Vessels Is Correlated with the Recurrence of Chronic Subdural Hematoma: a Prospective Study. Transl Stroke Res 2023:10.1007/s12975-023-01227-4. [PMID: 38133745 DOI: 10.1007/s12975-023-01227-4] [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: 09/27/2023] [Revised: 11/15/2023] [Accepted: 12/08/2023] [Indexed: 12/23/2023]
Abstract
Meningeal lymphatic vessels (mLVs) were recently discovered to be involved in the waste drainage process in the brain, which has also been associated with a variety of neurological diseases. This research paper hypothesizes that the drainage function of mLVs may be affected after chronic subdural hematoma (CSDH) and the alterations of mLVs' drainage may predict CSDH recurrence. In this prospective observational study, unenhanced 3D T2-fluid-attenuated inversion recovery (3D T2-FLAIR) MRI data were collected from CSDH patients and healthy participants for analysis. Patients with CSDH who underwent surgery received MRI scans before and after surgery, whereas healthy controls and patients with CSDH who received pharmaceutical treatment received only one MRI scan at enrollment. The signal unit ratio (SUR) of mLVs were then measured according to the MRI data and calculated to define mLVs' drainage function. Finally, the relationship between mLVs' drainage function and CSDH recurrence was analyzed accordingly. Thirty-four participants were enrolled in this study, including 27 CSDH patients and 7 controls. The SUR of mLVs in all CSDH patients changed significantly before and after surgery. Moreover, the drainage function of the mLVs ipsilateral to hematoma (mLVs-IH) in CSDH patients was significantly lower than that in the controls (p < 0.05). Last, a higher improvement rate of the drainage function of the mLVs-IH is correlated to a lower risk of recurrence (p < 0.05). This study revealed the mLVs' drainage dysfunction after CSDH through non-invasive MRI. Furthermore, the drainage function of mLVs is an independent predictive factor of CSDH recurrence.
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Affiliation(s)
- Jiahao Zhang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Lei Yu
- Department of Radiology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xiaoyu Wang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Qian Yu
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Bingrui Zhu
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Haocheng Zhang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Yibo Liu
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Huaming Li
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Anke Zhang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Kaikai Wang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Yezhao He
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Qun Wu
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Yuanjian Fang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China.
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China.
| | - Jianzhong Sun
- Department of Radiology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.
| | - Sheng Chen
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China.
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China.
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Salih M, Young M, Garcia A, Stippler M, Papavassiliou E, Alterman RL, Thomas AJ, Taussky P, Moore J, Ogilvy CS. Outcome of Chronic Subdural Hematoma Intervention in Patients on Long-Term Antiplatelet Therapy-A Propensity Score Matched Analysis. Neurosurgery 2023; 93:586-591. [PMID: 36921243 DOI: 10.1227/neu.0000000000002452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 01/13/2023] [Indexed: 03/17/2023] Open
Abstract
BACKGROUND Patients presenting with chronic subdural hematomas (cSDHs) and on antiplatelet medications for various medical conditions often complicate surgical decision making. OBJECTIVE To evaluate risks of preprocedural and postprocedural antiplatelet use in patients with cSDHs. METHODS Patients with cSDH who were treated between January 2006 and February 2022 at a single institution with surgical intervention were identified. A propensity score matching analysis was then performed analyzing length of hospitalization, periprocedural complications, reintervention rate, rebleeding risk, and reintervention rates. RESULTS Preintervention, 178 patients were on long-term antiplatelet medication and 298 were not on any form of antiplatelet. Sixty matched pairs were included in the propensity score analysis. Postintervention, 88 patients were resumed on antiplatelet medication, whereas 388 patients did not have resumption of antiplatelets. Fifty-five pairs of matched patients were included in the postintervention propensity score analysis. No significant differences were found in length of hospitalization (7.8 ± 4.2 vs 6.8 ± 5.4, P = .25), procedural complications (3.3% vs 6.7%, P = .68), or reintervention during the same admission (3.3% vs 5%, P = 1). No significant differences were seen in recurrence rate (9.1% vs 10.9%, P = 1) or reintervention rate after discharge (7.3% vs 9.1%, P = 1) in the postintervention group. CONCLUSION Preintervention antiplatelet medications before cSDH treatment do not affect length of hospitalization, periprocedural complications, or reintervention. Resumption of antiplatelet medication after cSDH procedures does not increase the rebleeding risk or reintervention rate.
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Affiliation(s)
- Mira Salih
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston , Massachusetts , USA
| | - Michael Young
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston , Massachusetts , USA
| | - Alfonso Garcia
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston , Massachusetts , USA
| | - Martina Stippler
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston , Massachusetts , USA
| | - Efstathios Papavassiliou
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston , Massachusetts , USA
| | - Ron L Alterman
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston , Massachusetts , USA
| | - Ajith J Thomas
- Department of Neurological Surgery, Cooper University Health Care, Cooper Medical School of Rowan University, Camden, New Jersey , USA
| | - Philipp Taussky
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston , Massachusetts , USA
| | - Justin Moore
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston , Massachusetts , USA
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston , Massachusetts , USA
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Miah IP, Blanter A, Tank Y, Zwet EWV, Rosendaal FR, Peul WC, Dammers R, Holl DC, Lingsma HF, den Hertog HM, van der Naalt J, Jellema K, der Gaag NAV. Change in Hematoma Size after Dexamethasone Therapy in Chronic Subdural Hematoma Subtypes: A Prospective Study in Symptomatic Patients. J Neurotrauma 2023; 40:228-239. [PMID: 36029208 DOI: 10.1089/neu.2022.0024] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
The main treatment strategy for chronic subdural hematoma is surgical intervention. When a conservative pharmacological approach is considered in symptomatic patients, mainly dexamethasone therapy is applied. Recent trials revealed dexamethasone therapy to be an ineffective treatment in symptomatic patients with chronic subdural hematoma. Whether the efficacy of dexamethasone therapy differs in radiological hematoma subtypes is unknown. The aim of this substudy was to identify which hematoma subtype might be favorable for dexamethasone therapy. As part of a randomized controlled trial, symptomatic chronic subdural hematoma patients received 19-days dexamethasone therapy. The primary outcome measure was the change in hematoma size as measured on follow-up computed tomography (CT) after 2 weeks of dexamethasone in six hematoma (architectural and density) subtypes: homogeneous total, laminar, separated and trabecular architecture types, and hematoma without hyperdense components (homogeneous hypodense, isodense) and with hyperdense components (homogeneous hyperdense, mixed density). We analyzed hematoma thickness, midline shift, and volume using multi-variable linear regression adjusting for age, sex and baseline value of the specific radiological parameter. From September 2016 until February 2021, 85 patients were included with a total of 114 chronic subdural hematoma. The mean age was 76 years and 25% were women. Larger decrease in hematoma thickness and midline shift was revealed in hematoma without hyperdense components compared with hematoma with hyperdense components (adjusted [adj.] b -2.2 mm, 95% confidence interval [CI] -4.1 to -0.3 and adj. b -1.3 mm, 95% CI -2.7 to 0.0 respectively). Additional surgery was performed in 57% of patients with the highest observed rate (81%) in separated hematoma. Largest hematoma reduction and better clinical improvement was observed in chronic subdural hematoma without hyperdense components after dexamethasone therapy. Evaluation of these parameters can be part of an individualized treatment strategy.
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Affiliation(s)
- Ishita P Miah
- Department of Neurology, Amphia Hospital, Breda, the Netherlands
- Department of Neurology and Neurosurgery, Leiden University Medical Center, Leiden, the Netherlands
- Department of Neurology and Neurosurgery, Haaglanden Medical Center, The Hague, the Netherlands
| | - Anastassia Blanter
- Department of Neurology and Neurosurgery, Haga Teaching Hospital, The Hague, the Netherlands
| | - Yeliz Tank
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Erik W van Zwet
- Department of Medical Statistics, Leiden University Medical Center, Leiden, the Netherlands
| | - Frits R Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Wilco C Peul
- Department of Neurology and Neurosurgery, Leiden University Medical Center, Leiden, the Netherlands
- Department of Neurology and Neurosurgery, Haaglanden Medical Center, The Hague, the Netherlands
- Department of Neurology and Neurosurgery, Haga Teaching Hospital, The Hague, the Netherlands
| | - Ruben Dammers
- Department of Neurosurgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Dana C Holl
- Department of Neurosurgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Hester F Lingsma
- Department of Public Health and Medical Decision Making, Erasmus Medical Center, Rotterdam, the Netherlands
| | | | - Joukje van der Naalt
- Department of Neurology, University Medical Center Groningen, Groningen, the Netherlands
| | - Korné Jellema
- Department of Neurology and Neurosurgery, Haaglanden Medical Center, The Hague, the Netherlands
| | - Niels A Van der Gaag
- Department of Neurology and Neurosurgery, Leiden University Medical Center, Leiden, the Netherlands
- Department of Neurology and Neurosurgery, Haaglanden Medical Center, The Hague, the Netherlands
- Department of Neurology and Neurosurgery, Haga Teaching Hospital, The Hague, the Netherlands
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Abdullah HM, Dakurah T, Akoto H, Abaidoo B, Dakubo JCB, Yawson AE, Wepeba G, Bankah P, Boatey J, Ametefe M, Nketiah-Boakye F, Fuseini A, Banson M, Ndanu T, Mubarak A, Iddrissu M. Predictors of recurrence of chronic subdural haematoma in a cohort study of patients presenting in a sub-Saharan African teaching hospital. BMC Neurol 2022; 22:346. [PMID: 36104782 PMCID: PMC9472341 DOI: 10.1186/s12883-022-02857-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 08/29/2022] [Indexed: 11/16/2022] Open
Abstract
Background Chronic subdural haematoma (CSDH) is a common neurological condition affecting the elderly with decreased quality of life. Recurrence leads to increase in number of hospital admissions and surgical interventions. Several factors contribute to recurrence of chronic subdural haematoma, and determination of these factors will help institute measures to reduce recurrence of CSDH, cost of care and improved quality of life. The aim of this study was to determine the predictors of recurrence of chronic subdural haematoma in a cohort of patients presenting in a Sub-Saharan African Teaching Hospital. Methods A prospective hospital-based cohort study of 62 participants who presented with CSDH and underwent burr-hole and drainage at the Neuroscience unit of the Korle-bu Teaching Hospital. The primary outcome of this study was the recurrence of CSDH within 3 months after the surgery. Data was entered into Microsoft Excel 2016 and exported to International Business Machine (IBM) Statistical Package for the Social Sciences (SPSS) version 21.0 for analysis. Predictors of recurrence of CSDH were determined using logistic regression with odds ratio calculated at the 95% confidence level and a p-value less than 0.05 accepted as statistically significant. Results There was a male preponderance of 45 (72.6%), over females of 17 (27.4%). The mean age was 63.1 ± 13.6 years. The recurrence rate of CSDH was 21.0% whilst the mortality rate was 4.8%. Facial palsy and dysphasia were associated with the recurrence of CSDH (p = 0.045, 0.029). Hypertension and bilaterality were associated with recurrence of CSDH from a univariate analysis (p = 0.039, OR = 4.865, CI = 0.975–24.285; p = 0.005, OR = 5.979, CI = 1.585–22.557). In a multivariate logistic regression analysis, bilaterality was the only independent predictor of recurrence of CSDH (p = 0.030, AOR = 5.47, CI = 1.18–25.34). Conclusions Both hypertension and bilaterality showed statistically significant association with recurrence of CSDH. However, only bilaterality proved to be an independent predictor of recurrence of CSDH in patient who underwent burr-hole and drainage. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-022-02857-1.
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Bader SE, Sönnerqvist C, Melander N, Olivecrona M. A Validation Study of Kwon's Prognostic Scoring System for Chronic Subdural Hematoma. World Neurosurg 2022; 165:e365-e372. [PMID: 35724882 DOI: 10.1016/j.wneu.2022.06.062] [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: 03/27/2022] [Revised: 06/10/2022] [Accepted: 06/11/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Surgery for chronic subdural hematoma is one of the most frequent operations in neurosurgical practice. Chronic subdural hematoma mostly afflicts the elderly population. In 2018, Kwon and co-workers, published the Kwon scoring system (KSS), whereby 6 clinical and radiological factors are used to facilitate, and promote quality in, surgical decision-making and counseling of relatives. The aim of this study is to validate the KSS. METHODS Patients operated on for unilateral chronic subdural hematoma at Örebro University Hospital, Sweden, between 2013 and 2019 constituted the study population. General data and the 6 outcome predictors according to the KSS were extracted from the electronic patient records. The preoperative modified Rankin Scale score and the postoperative 6-month modified Rankin Scale score were assessed. RESULTS We identified 133 patients (69.2% male) with a median age of 80.2 years (interquartile range 72.6-85.9). The median Glasgow Coma Scale score at admission was 15; 57.1% had motor deficits and 36.81% were disoriented. For 39.1% of the patients, the prognosis was a favorable outcome (modified Rankin Scale 0-1) at 6 months. The median KSS score was 9; 63.9% of the patients scored ≥9, and 36 (42.4%) of these patients actually achieved a favorable outcome. This corresponds to a prediction model sensitivity of 0.667 and specificity of 0.424. A receiver operator characteristic curve analysis of the model yielded an area under the receiver operator characteristic curve of 0.62441. CONCLUSIONS In our material, the KSS did not predict outcome precisely enough to base treatment decisions or counseling of relatives on the scores obtained.
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Affiliation(s)
- Sam Er Bader
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Caroline Sönnerqvist
- Department of Paediatrics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Nils Melander
- Deptartment of Neurology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Magnus Olivecrona
- Department of Neurosurgery Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
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Mignucci-Jiménez G, Matos-Cruz AJ, Abramov I, Hanalioglu S, Kovacs MS, Preul MC, Feliciano-Valls CE. Puerto Rico Recurrence Scale: Predicting chronic subdural hematoma recurrence risk after initial surgical drainage. Surg Neurol Int 2022; 13:230. [PMID: 35855136 PMCID: PMC9282733 DOI: 10.25259/sni_240_2022] [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: 03/09/2022] [Accepted: 05/05/2022] [Indexed: 11/04/2022] Open
Abstract
Background: Chronic subdural hematoma (CSDH) commonly affects older individuals and is associated with a relatively high rate of recurrence after surgery. Many studies have created grading systems to identify patients at high risk of CSDH recurrence after the initial surgery. However, no system has been adopted widely. The authors present the first CSDH grading system created from a population-based single-center data set. Methods: A single-center Puerto Rican population-based retrospective analysis was performed on consecutive patients treated for a CSDH at a designated institution from July 1, 2017 to December 31, 2019. Univariate and multivariate analyses were used to create a CSDH recurrence grading scale. Retrospective validation was conducted on this sample population. Results: The study included 428 patients. Preoperative midline shift, postoperative midline shift, and size of postoperative subdural space differed between the recurrence and nonrecurrence groups (P = 0.03, 0.002, and 0.002, respectively). A multivariate analysis was used to create a 10-point grading scale comprising four independent variables. Recurrence rates progressively increased from the low-risk (0–3 points) to high-risk (8–10 points) groups (2.9% vs. 20.3%; P < 0.001). Conclusion: A 10-point grading scale for CSDH recurrence was developed with four components: preoperative midline shift (≤1 and >1 cm), laterality (bilateral, unilateral-right, and unilateral-left), size of postoperative subdural space (≤1.6 and >1.6 cm), and pneumocephalus (present or absent). Patients who scored higher on the scale had a higher risk of recurrence. This CSDH grading scale has implications for Puerto Rico and the general population as the elderly population increases worldwide.
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Affiliation(s)
- Giancarlo Mignucci-Jiménez
- Department of Surgery, Neurosurgery Section, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico, United States,
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona, United States,
| | - Alejandro J. Matos-Cruz
- Department of Surgery, Neurosurgery Section, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico, United States,
- Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, Pennsylvania, United States
| | - Irakliy Abramov
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona, United States,
| | - Sahin Hanalioglu
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona, United States,
| | - Melissa S. Kovacs
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona, United States,
| | - Mark C. Preul
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona, United States,
| | - Caleb E. Feliciano-Valls
- Department of Surgery, Neurosurgery Section, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico, United States,
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Jang TH, Paeng SH, Shim YW, Lee WH, Kim ST, Lee KS. Delayed Multiple Intracerebral Hemorrhage After Burr Hole Drainage of Chronic Subdural Hematoma During Failure of Warfarin Resumption in Atrial Fibrillation. Korean J Neurotrauma 2022; 18:83-88. [PMID: 35557631 PMCID: PMC9064741 DOI: 10.13004/kjnt.2022.18.e9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 12/26/2021] [Accepted: 01/10/2022] [Indexed: 11/15/2022] Open
Affiliation(s)
- Tae Hoon Jang
- Department of Neurosurgery, School of Medicine, Inje University Busan Paik Hospital, Busan, Korea
| | - Sung Hwa Paeng
- Department of Neurosurgery, School of Medicine, Inje University Busan Paik Hospital, Busan, Korea
| | - Yong woo Shim
- Department of Neurosurgery, Gyungnam Military Manpower Administration, Changwon, Korea
| | - Won Hee Lee
- Department of Neurosurgery, School of Medicine, Inje University Busan Paik Hospital, Busan, Korea
| | - Sung-Tae Kim
- Department of Neurosurgery, School of Medicine, Inje University Busan Paik Hospital, Busan, Korea
| | - Keun Soo Lee
- Department of Neurosurgery, School of Medicine, Inje University Busan Paik Hospital, Busan, Korea
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9
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Tamura R, Sato M, Yoshida K, Toda M. History and current progress of chronic subdural hematoma. J Neurol Sci 2021; 429:118066. [PMID: 34488045 DOI: 10.1016/j.jns.2021.118066] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Revised: 08/25/2021] [Accepted: 08/31/2021] [Indexed: 11/18/2022]
Abstract
Chronic subdural hematoma (CSDH) is characterized by an encapsulated collection of old blood. Although CSDH has become the most frequent pathologic entity in daily neurosurgical practice, there are some unresolved research questions. In particular, the causes and recurrent risk factors of CSDH remain as an object of debate. The split of the dural border layer forms a few tiers of dural border cells over the arachnoid layer. Tissue plasminogen activator plays an important role as a key factor of defective coagulation. Historically, CSDH has often been treated via burr hole craniostomy using a closed drainage system. Several different operative strategies and peri-operative strategies such as the addition of burr holes, addition of cavity irrigation, position of drain, or postural position, have been described previously. Although the direction of the drainage tube, residual air, low intensity of T1-weighted images on MRI, and niveau formation have been reported as risk factors for recurrence, antiplatelet or anticoagulant drug use has not yet been verified as a risk factor. Recently, pharmaceutical strategies, including atorvastatin, significantly improved the neurological function in CSDH patients. Many case series, without randomization, have been reported; and given its promising result, several randomized clinical trials using pharmaceutical as well as operative and perioperative strategies were initiated to obtain sufficient data. In contrast, relatively fewer basic studies have achieved clinical applications in CSDH, although it is one of the most common clinical entities. Further scientific basic research may be essential for achieving a novel treatment strategy for CSDH.
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Affiliation(s)
- Ryota Tamura
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan; Department of Neurosurgery, Kawasaki Municipal Hospital, Shinkawadori, Kawasaki-ku, Kanagawa 210-0013, Japan
| | - Mizuto Sato
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Kazunari Yoshida
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Masahiro Toda
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan.
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10
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Petrella L, Muscas G, Montemurro VM, Lastrucci G, Fainardi E, Pansini G, Della Puppa A. Use of the Subdural Hematoma in the Elderly (SHE) Score to Predict 30-Day Mortality After Chronic Subdural Hematoma Evacuation. World Neurosurg 2021; 157:e294-e300. [PMID: 34648990 DOI: 10.1016/j.wneu.2021.10.072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 10/01/2021] [Accepted: 10/04/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND The Subdural Hematoma in the Elderly (SHE) score has been recently developed to assess the 30-day mortality in acute and chronic subdural hematomas in patients >65 years and has shown good reliability. We aimed to validate the SHE score's accuracy to predict 30-day mortality on a homogeneous cohort of patients undergoing surgical chronic subdural hematoma evacuation at our Institution. We also investigated whether the SHE score could reliably predict the occurrence of 30-day chronic subdural hematoma recurrence needing surgery. METHODS We included patients from our prospectively collected database from January 2018 to January 2021. Patients with the availability of the following information were enrolled: age, Glasgow Coma Scale score on admission, hematoma volume, medical history, and outcome at 30 days. The SHE score was calculated for each patient, and the association between greater scores and 30-day mortality was investigated and its ability to predict 30-day and disease recurrence. Statistical significance was assessed for P < 0.05. RESULTS Three hundred twenty-one patients were included. Of them, 40 (12.5%) displayed mortality within 30-day: specifically, 0% of the group of patients with SHE score = 0, 4.3% of SHE score = 1, 14.5% of SHE score = 2, 39.3% of SHE score = 3, and 37.5% of SHE score = 4, with a statistically significant linear trend between greater SHE scores and 30-day mortality rates (P < 0.001, area under the curve 0.75 [0.67-0.82]). No significant association of the SHE score with the risk of recurrence needing surgery was detected (P = 0.4). CONCLUSIONS The SHE score proved helpful in predicting 30-day mortality in patients with chronic subdural hematomas, but no utility was observed to predict disease recurrence.
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Affiliation(s)
- Luca Petrella
- Department of Neurosurgery, Department of Neuroscience, Psychology, Drug Area and Child Health (NEUROFARBA), Florence, Italy
| | - Giovanni Muscas
- Department of Neurosurgery, Department of Neuroscience, Psychology, Drug Area and Child Health (NEUROFARBA), Florence, Italy.
| | - Vita Maria Montemurro
- Department of Neurosurgery, Department of Neuroscience, Psychology, Drug Area and Child Health (NEUROFARBA), Florence, Italy
| | - Giancarlo Lastrucci
- Department of Neurosurgery, Department of Neuroscience, Psychology, Drug Area and Child Health (NEUROFARBA), Florence, Italy
| | - Enrico Fainardi
- Neuroradiology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Careggi University Hospital, Florence, Italy
| | - Gastone Pansini
- Department of Neurosurgery, Department of Neuroscience, Psychology, Drug Area and Child Health (NEUROFARBA), Florence, Italy
| | - Alessandro Della Puppa
- Department of Neurosurgery, Department of Neuroscience, Psychology, Drug Area and Child Health (NEUROFARBA), Florence, Italy
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11
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Lizana J, Aliaga N, Basurco A. Hematoma subdural crónico: Una patología común de manejo complejo. Surg Neurol Int 2021. [DOI: 10.25259/sni_676_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Antecedentes:
El hematoma subdural crónico (HSDC) es una patología ampliamente estudiada, muy frecuente, sobre todo en adultos mayores; su cuadro clínico tiene una apariencia benigna y suele ir acompañado de múltiples comorbilidades asociadas a la edad, lo que resulta en un aumento de las complicaciones e incluso la muerte. Con el incremento de la expectativa de vida a nivel mundial, el uso de medicamentos antitrombóticos es cada vez más frecuente. El papel de estos fármacos en la evolución de la enfermedad como en la recurrencia, sigue siendo motivo de discusión.
Métodos:
Los autores revisaron la fisiopatología y características clínicas del HSDC. El presente artículo discute acerca de las terapéuticas actuales y las nuevas opciones de tratamiento que podrían mejorar los resultados. Este manuscrito es susceptible de cambios en el tiempo, con el desarrollo científico y tecnológico.
Resultados:
El HSDC puede ser abordado por vía quirúrgica y farmacológica; no obstante, un manejo individualizado requiere la consideracion cuidadosa de diversos factores. A pesar de los avances en el campo de la neurocirugía, la clásica trepanación craneal sigue siendo el Gold estándar en el HSDC y sobre todo en pacientes con síntomas graves. Se debe resaltar que aún hay aspectos de este procedimiento (como la localización del dren, número de drenajes, el efecto de la irrigación, la temperatura de la solución con que se irriga, etc.) que siguen siendo materia de estudio.
Conclusiones:
Entender el mecanismo de la enfermedad ha permitido explicar su historia natural y a su vez proponer nuevas alternativas de tratamiento. El manejo médico (atorvastatina, corticoides) ha generado gran interés por sus alentadores resultados preliminares. Recientemente, se ha reportado la terapia endovascular como una alternativa segura y existe gran expectativa por confirmar su efecto en estudios más grandes.
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Affiliation(s)
- Jafeth Lizana
- Department of Neurosurgery, Hospital Nacional Guillermo Almenara, Lima, Peru,
| | - Nelida Aliaga
- Department of Medicine, School of Biomedical Sciences, Austral University, Mariano Acosta, Buenos Aires, Argentina
| | - Alfonso Basurco
- Department of Neurosurgery, Hospital Nacional Guillermo Almenara, Lima, Peru,
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12
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Yuan J, Li Y, Liu X, Nie M, Jiang W, Fan Y, Xiang T, Wang H, Quan W, Gao C, Huang J, An S, Ru Y, Zhou Q, Zhang J, Jiang R. Atorvastatin Plus Low-Dose Dexamethasone May Be Effective for Leukemia-Related Chronic Subdural Hematoma but Not for Leukemia Encephalopathy: A Report of Three Cases. Front Oncol 2021; 11:628927. [PMID: 34336644 PMCID: PMC8320332 DOI: 10.3389/fonc.2021.628927] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 06/30/2021] [Indexed: 01/07/2023] Open
Abstract
We are not aware of any reports regarding conservative treatment for leukemia-related chronic subdural hematoma (CSDH). We report our experience with 3 men who were admitted with subdural masses and abnormal leukocyte counts. In two patients, leukemia and CSDH were confirmed on the basis of medical records, mild head trauma, and neuroimaging features. Both patients experienced reduced CSDH and neurological symptoms after receiving atorvastatin (20 mg/day) plus low-dose dexamethasone. However, this combined conservative treatment was ineffective in the third patient, who was diagnosed as having leukemia and showed an increased hematoma volume after two weeks of therapy. Magnetic resonance imaging findings suggested dural metastasis, which prompted a switch from statin-based conservative treatment to chemotherapy. Complete remission of the leukemia and resolution of the subdural mass were observed after chemotherapy, which supported a diagnosis of leukemia encephalopathy. The 5-month follow-ups did not reveal CSDH relapse in all 3 cases. Thus, atorvastatin-based conservative treatment may be effective for leukemia-related CSDH but not for leukemia encephalopathy.
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Affiliation(s)
- Jiangyuan Yuan
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Ying Li
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Xuanhui Liu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Meng Nie
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Weiwei Jiang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Yibing Fan
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Tangtang Xiang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Hanhua Wang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Wei Quan
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Chuang Gao
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Jinghao Huang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Shuo An
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Yongxin Ru
- Department of Clinical Laboratory, Hospital of Hematology, Chinese Academy of Medical Sciences, Tianjin, China
| | - Qiufan Zhou
- Department of Hematology, Tianjin Medical University General Hospital, Tianjin, China
| | - Jianning Zhang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Rongcai Jiang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
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13
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Pan Z, Bao J, Wei S. Efficacy of the Direct Aspiration-Irrigation Maneuver for the Treatment of Chronic Subdural Hematoma: A Single Hospital's Experience. Cureus 2021; 13:e16231. [PMID: 34268061 PMCID: PMC8262522 DOI: 10.7759/cureus.16231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2021] [Indexed: 11/05/2022] Open
Abstract
Objective The traditional methods for managing symptomatic chronic subdural hematoma (CSDH) at our hospital include evacuation via single burr-hole irrigation with continuous closed subdural drainage (SBID). The single burr-hole aspiration and irrigation technique with continuous closed subdural drainage (SBAID) is an attractive alternative method. The goal of this study was to evaluate the radiographic and clinical outcomes of SBAID compared with traditional SBID methods. Methods A database of 51 CSDH patients treated with the SBAID method and 35 CSDH patients treated with the SBID method was compiled, and a retrospective chart review was performed. Information regarding demographics, comorbidities, presenting symptoms, and outcomes were collected. Predictors of recurrence requiring reoperation and other outcomes were analyzed. Results Compared to the patients in the SBID group, the patients in the SBAID group had a shorter mean duration of surgery (56.6±5.6 minutes vs 59.5±4.8 minutes, respectively, P=0.02); a shorter mean interval from procedure to discharge (6.2±1.2 days vs 6.8±1.3 days, respectively, P=0.046); no significant difference in preoperative hematoma volume (106.4±21.7 cm3 vs 101.3±16.3 cm3, respectively, P=0.25); and a smaller subdural space volume 48 hours after the operation (43.6±7.4 cm3 vs 47.4±9.1 cm3, respectively, P=0.03). In addition, symptomatic hematoma recurrence developed in one patient in the SBAID group and five patients in the SBID group (P=0.03). The in-hospital mortality rates of the SBAID and SBID groups were 2% (1 of 51) and 6% (2 of 35), respectively; this difference was not statistically significant (P=0.35). Conclusions The SBAID method results in a remarkably low recurrence rate and good outcomes. This method should be considered for patients presenting with symptomatic CSDHs.
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Affiliation(s)
- Zhenjiang Pan
- Neurosurgery, Shidong Hospital of Yangpu District, Shanghai, CHN
| | - Jing Bao
- Neurosurgery, Shidong Hospital of Yangpu District, Shanghai, CHN
| | - Shepeng Wei
- Neurosurgery, Shidong Hospital of Yangpu District, Shanghai, CHN
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14
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Impact of acetylsalicylic acid in patients undergoing cerebral aneurysm surgery - should the neurosurgeon really worry about it? Neurosurg Rev 2021; 44:2889-2898. [PMID: 33495921 PMCID: PMC8490225 DOI: 10.1007/s10143-021-01476-7] [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: 09/08/2020] [Revised: 12/16/2020] [Accepted: 01/08/2021] [Indexed: 11/03/2022]
Abstract
There has been an increase in the use of acetylsalicylic acid (ASA, Aspirin®) among patients with stroke and heart disease as well as in aging populations as a means of primary prevention. The potentially life-threatening consequences of a postoperative hemorrhagic complication after neurosurgical operative procedures are well known. In the present study, we evaluate the risk of continued ASA use as it relates to postoperative hemorrhage and cardiopulmonary complications in patients undergoing cerebral aneurysm surgery. We retrospectively analyzed 200 consecutive clipping procedures performed between 2008 and 2018. Two different statistical models were applied. The first model consisted of two groups: (1) group with No ASA impact - patients who either did not use ASA at all as well as those who had stopped their use of the ASA medication in time (> = 7 days prior to operation); (2) group with ASA impact - all patients whose ASA use was not stopped in time. The second model consisted of three groups: (1) No ASA use; (2) Stopped ASA use (> = 7 days prior to operation); (3) Continued ASA use (did not stop or did not stop in time, <7 days prior to operation). Data collection included demographic information, surgical parameters, aneurysm characteristics, and all hemorrhagic/thromboembolic complications. A postoperative hemorrhage was defined as relevant if a consecutive operation for hematoma removal was necessary. An ASA effect has been assumed in 32 out of 200 performed operations. A postoperative hemorrhage occurred in one out these 32 patients (3.1%). A postoperative hemorrhage in patients without ASA impact was detected and treated in 5 out of 168 patients (3.0%). The difference was statistically not significant in either model (ASA impact group vs. No ASA impact group: OR = 1.0516 [0.1187; 9.3132], p = 1.000; RR = 1.0015 [0.9360; 1.0716]). Cardiopulmonary complications were significantly more frequent in the group with ASA impact than in the group without ASA impact (p = 0.030). In this study continued ASA use was not associated with an increased risk of a postoperative hemorrhage. However, cardiopulmonary complications were significantly more frequent in the ASA impact group than in the No ASA impact group. Thus, ASA might relatively safely be continued in patients with increased cardiovascular risk and cases of emergency cerebrovascular surgery.
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15
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Nouri A, Gondar R, Schaller K, Meling T. Chronic Subdural Hematoma (cSDH): A review of the current state of the art. BRAIN AND SPINE 2021; 1:100300. [PMID: 36247395 PMCID: PMC9560707 DOI: 10.1016/j.bas.2021.100300] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Introduction Incidence of Chronic Subdural Hematoma (cSDH) is rising worldwide, partly due to an aging population, but also due to increased use of antithrombotic medication. Many recent studies have emerged to address current cSDH management strategies. Research question What is the state of the art of cSDH management. Material and methods Review. Results Head trauma, antithrombotic use and craniocerebral disproportion increase the risk of cSDH development. Most patients present with disorientation, GCS 13–15, and symptoms arising from cortical irritation and increased intracranial pressure. cSDH occurs bilaterally in 9–22%. CT allows assessment of cerebral compression (herniation, hematoma thickness, ventricle collapse, midline shift), hematoma age and presence of membranes, factors that ultimately determine treatment urgency and surgical approach. Recurrence remains the principle complication (9–33%), occurring more commonly with older age and bilateral cSDHs. Discussion and conclusion While incompletely understood, it is generally believed that injury in the dural cell layer results in bleeding from bridging veins, resulting in a hematoma formation, with or without a preceding hygroma, in a potential space approximating the junction between the dura and arachnoid. Neovascularization and leaking from the outer membrane are thought to propagate this process. Evidence that MMA embolization may reduce recurrence rates is a potentially exciting new treatment option, but also supports the theory that the MMA is implicated in the cSDH pathophysiology. The use of steroids remains a controversial topic without clear treatment guidelines. cSDH represents a common neurosurgical problem with burr-hole treatment remaining the gold standard, often in conjunction with subgaleal drains. MMA embolization to stop recurrence may represent an important evolution in understanding the pathophysiology of cSDH and improving treatment. Incidence of cSDH is rising, partly due to the aging population and increased antithrombotic use. cSDH occurs bilaterally in 9–22% of cases. Recurrence remains the principle complication and has been estimated at 9–33%. Risk factors for recurrence include old age and bilateral cSDHs. MMA embolization may reduce recurrence, but its efficacy and target population remain unclear.
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16
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Todeschi J, Ferracci FX, Metayer T, Gouges B, Leroy HA, Hamdam N, Bougaci N, De Barros A, Timofeev A, Pretat PH, Bannwarth M, Roblot P, Peltier C, Lleu M, Pommier B, Chibbaro S, Proust F, Cebula H. Impact of discontinuation of antithrombotic therapy after surgery for chronic subdural hematoma. Neurochirurgie 2020; 66:195-202. [DOI: 10.1016/j.neuchi.2020.04.136] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 03/26/2020] [Accepted: 04/05/2020] [Indexed: 02/08/2023]
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17
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Chang CL, Sim JL, Delgardo MW, Ruan DT, Connolly ES. Predicting Chronic Subdural Hematoma Resolution and Time to Resolution Following Surgical Evacuation. Front Neurol 2020; 11:677. [PMID: 32760342 PMCID: PMC7371920 DOI: 10.3389/fneur.2020.00677] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 06/05/2020] [Indexed: 12/26/2022] Open
Abstract
Background: Growing evidence suggests that chronic subdural hematoma (CSDH) may have long-term adverse effects even after surgical evacuation. Hematoma recurrence is commonly reported as a short-term, postoperative outcome measure for CSDH, but other measures such as hematoma resolution may provide better insight regarding mechanisms behind longer-term sequelae. This study aims to characterize postoperative resolution times and identify predictors for this relatively unexplored metric. Methods: Consecutive cases (N = 122) of burr hole evacuation for CSDH by a single neurosurgeon at Columbia University Irving Medical Center from 2000 to 2019 were retrospectively identified. Patient characteristics, presenting factors, and date of hematoma resolution were abstracted from the electronic health record. Outcome measures included CSDH resolution at 6 months, surgery-to-resolution time, and inpatient mortality. Univariate and multivariate analyses were performed to determine predictors of outcome measures. Results: Hematoma resolution at 6 months was observed in 58 patients (47.5%), and median surgery-to-resolution time was 161 days (IQR: 85-367). Heavy drinking was predictive of non-resolution at 6 months and longer surgery-to-resolution time, while increased age was predictive of non-resolution at 6 months. Antiplatelet agent resumption was associated with non-resolution at 6 months and longer surgery-to-resolution time on univariate analysis but was not significant on multivariate analysis. Conclusion: Postoperative resolution times for most CSDHs are on the order of several months to a year, and delayed resolution is linked to heavy drinking and advanced age. Subsequent prospective studies are needed to directly assess the utility of hematoma resolution as a potential metric for long-term functional and cognitive outcomes of CSDH.
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Affiliation(s)
- Cory L Chang
- Cerebrovascular Research Laboratory, Department of Neurological Surgery, Columbia University Irving Medical Center, New York, NY, United States
| | - Justin L Sim
- Cerebrovascular Research Laboratory, Department of Neurological Surgery, Columbia University Irving Medical Center, New York, NY, United States
| | - Mychael W Delgardo
- Cerebrovascular Research Laboratory, Department of Neurological Surgery, Columbia University Irving Medical Center, New York, NY, United States
| | - Diana T Ruan
- Cerebrovascular Research Laboratory, Department of Neurological Surgery, Columbia University Irving Medical Center, New York, NY, United States
| | - E Sander Connolly
- Cerebrovascular Research Laboratory, Department of Neurological Surgery, Columbia University Irving Medical Center, New York, NY, United States
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18
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Long-term excess mortality after chronic subdural hematoma. Acta Neurochir (Wien) 2020; 162:1467-1478. [PMID: 32146525 PMCID: PMC7235063 DOI: 10.1007/s00701-020-04278-w] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 02/26/2020] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To assess possible long-term excess mortality and causes of death of patients with chronic subdural hematoma (CSDH). METHODS A retrospective study (1990-2015) of adult patients (n = 1133, median age = 76 years old, men = 65%) with CSDH identified by ICD-codes and verified by medical records. All patients were followed until death or the end of 2017. Cumulative relative survival ratios and relative excess risks of death (RER) were estimated by comparing patients' mortality with that in the entire regional matched population. The causes of death were compared with a separate reference group formed by randomly choosing sex, age, and calendar time matched controls (4 controls per each CSDH patient). RESULTS The median follow-up time was 4.8 years (range = 0-27 years), and 710 (63%) of the patients died (median age at death = 84 years old). The cumulative excess mortality was 1 year = 9%, 5 years = 18%, 10 years = 27%, 15 years = 37%, and 20 years = 48%. A subgroup of CSDH patients (n = 206) with no comorbidity had no excess mortality. Excess mortality was related to poor modified Rankin score at admission (RER = 4.93) and at discharge (RER = 8.31), alcohol abuse (RER = 4.47), warfarin (RER = 2.94), age ≥ 80 years old (RER = 1.83), non-operative treatment (RER = 1.56), and non-traumatic etiology (RER = 1.69). Hematoma characteristics or recurrence were unrelated to excess mortality. Dementia was the most common cause of death among the CSDH patients (21%) and the third most common cause in the reference group (15%, p < 0.001). CONCLUSIONS Patients with CSDH have continuous excess mortality up to 20 years after diagnosis. Patient-related characteristics have a strong association with excess mortality, whereas specific CSDH-related findings do not. CSDH patients have an increased risk for dementia-related mortality.
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19
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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
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20
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Rauhala M, Luoto TM, Huhtala H, Iverson GL, Niskakangas T, Öhman J, Helén P. The incidence of chronic subdural hematomas from 1990 to 2015 in a defined Finnish population. J Neurosurg 2020; 132:1147-1157. [DOI: 10.3171/2018.12.jns183035] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 12/26/2018] [Indexed: 01/17/2023]
Abstract
OBJECTIVEThe aim of this study was to determine the population-based epidemiology of chronic subdural hematoma (CSDH) over a 26-year period.METHODSA retrospective study was conducted of all adult patients (≥ 18 years and residents of Pirkanmaa [Finland]) with a diagnosis of CSDH between 1990 and 2015. The cases were identified using ICD codes. Detailed data collection was performed using medical records and death certificates. All patients were monitored until death or the end of year 2017. The annual number of inhabitants in the Pirkanmaa region was obtained from Statistics Finland (Helsinki, Finland).RESULTSA total of 1168 patients with CSDH were identified from hospital records and death certificates; patients were considered as new-incidence cases if 2 years had elapsed following primary treatment and in cases involving a new contralateral CSDH. From 1990 to 2015, the overall incidence of CSDH doubled from 8.2 to 17.6/100,000/year. Among adults younger than 70 years, the incidence remained quite stable, whereas the incidence clearly increased among the ≥ 80-year-old population, from 46.9 to 129.5/100,000/year. The median age for a CSDH diagnosis increased from 73 to 79 years during the 26-year period. Head trauma was documented in 59% of cases. A ground-level fall was related to the CSDH in 31% of patients younger than 60 years and in 54% of those 80 years or older. The proportion of alcohol-related cases decreased toward the end of the study period (1990–1995: 16% and 2011–2015: 7%), because alcohol abuse was less frequent among the growing group of elderly patients. In contrast, the percentage of patients receiving anticoagulant or antiplatelet medication almost doubled toward 2015 (1990–1995, 27%; and 2011–2015, 49%). The patients’ neurological condition on admission, based on both Glasgow Coma Scale score (score < 13: 1990–1995, 18%; and 2011–2015, 7%; p < 0.001) and the modified Rankin Scale score (score 0–2: 1990–1995, 8%; and 2011–2015, 19%; p < 0.001), was better in recent years than in the early 1990s.CONCLUSIONSFrom 1990 to 2015, the incidence of CSDH has increased markedly. The incidence of CSDH among the population 80 years or older has nearly tripled since 1990. The use of anticoagulants has increased, but there has been no change regarding the ratio between a traumatic and a spontaneous CSDH etiology. As the world population becomes progressively older, the increasing incidence of CSDH will be a burden to patients and a future challenge for neurosurgical clinics.
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Affiliation(s)
- Minna Rauhala
- 1Department of Neurosurgery, Tampere University Hospital and Tampere University, Tampere
| | - Teemu M. Luoto
- 1Department of Neurosurgery, Tampere University Hospital and Tampere University, Tampere
| | - Heini Huhtala
- 2Faculty of Social Sciences, Biostatistics Group, Tampere University, Tampere, Finland
| | - Grant L. Iverson
- 3Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital & Home Base, A Red Sox Foundation and Massachusetts General Hospital Program, Boston, Massachusetts; and
| | - Tero Niskakangas
- 1Department of Neurosurgery, Tampere University Hospital and Tampere University, Tampere
| | - Juha Öhman
- 4Faculty of Medicine and Life Sciences, Tampere University, Tampere, Finland
| | - Pauli Helén
- 1Department of Neurosurgery, Tampere University Hospital and Tampere University, Tampere
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Gasslander J, Sundström N, Eklund A, Koskinen LOD, Malm J. Risk factors for developing subdural hematoma: a registry-based study in 1457 patients with shunted idiopathic normal pressure hydrocephalus. J Neurosurg 2020; 134:668-677. [PMID: 31923893 DOI: 10.3171/2019.10.jns191223] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 10/29/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Subdural hematomas and hygromas (SDHs) are common complications in idiopathic normal pressure hydrocephalus (iNPH) patients with shunts. In this registry-based study, patients with shunted iNPH were screened nationwide to identify perioperative variables that may increase the risk of SDH. METHODS The Swedish Hydrocephalus Quality Registry was reviewed for iNPH patients who had undergone shunt surgery in Sweden in 2004-2014. Potential risk factors for SDH were recorded preoperatively and 3 months after surgery. Drug prescriptions were identified from a national pharmacy database. Patients who developed SDHs were compared with those without SDHs. RESULTS The study population consisted of 1457 patients, 152 (10.4%) of whom developed an SDH. Men developed an SDH more often than women (OR 2.084, 95% CI 1.421-3.058, p < 0.001). Patients on platelet aggregation inhibitors developed an SDH more often than those who were not (OR 1.733, 95% CI 1.236-2.431, p = 0.001). At surgery, shunt opening pressures had been set 5.9 mm H2O lower in the SDH group than in the no-SDH group (109.6 ± 24.1 vs 115.5 ± 25.4 mm H2O, respectively, p = 0.009). Antisiphoning devices (ASDs) were used in 892 patients but did not prevent SDH. Mean opening pressures at surgery and the follow-up were lower with shunts with an ASD, without causing more SDHs. No other differences were seen between the groups. CONCLUSIONS iNPH patients in this study were diagnosed and operated on in routine practice; thus, the results represent everyday care. Male sex, antiplatelet medication, and a lower opening pressure at surgery were risk factors for SDH. Physical status and comorbidity were not. ASD did not prevent SDH, but a shunt with an ASD allowed a lower opening pressure without causing more SDHs.
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Affiliation(s)
- Johan Gasslander
- 1Department of Pharmacology and Clinical Neuroscience, Umeå University, Umeå
- 2Departments of Cardiology and Health, Medicine and Caring Services, Linkoping University, Vrinnevi General Hospital Norrköping; and
| | - Nina Sundström
- 3Department of Radiation Sciences, Umeå University, Umeå, Sweden
| | - Anders Eklund
- 3Department of Radiation Sciences, Umeå University, Umeå, Sweden
| | - Lars-Owe D Koskinen
- 1Department of Pharmacology and Clinical Neuroscience, Umeå University, Umeå
| | - Jan Malm
- 1Department of Pharmacology and Clinical Neuroscience, Umeå University, Umeå
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Comparison of Clinical and Radiologic Characteristics and Prognosis of Patients with Chronic Subdural Hematoma with and without a History of Head Trauma. World Neurosurg 2019; 132:e391-e398. [DOI: 10.1016/j.wneu.2019.08.142] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 08/19/2019] [Accepted: 08/22/2019] [Indexed: 10/26/2022]
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Wakuta N, Abe H, Fukuda K, Nonaka M, Morishita T, Arima H, Inoue T. Feasibility and Safety of Endoscopic Procedure in Burr-Hole Surgery for Chronic Subdural Hematoma in Patients of Very Advanced Age. World Neurosurg 2019; 134:e1037-e1046. [PMID: 31759155 DOI: 10.1016/j.wneu.2019.11.080] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Accepted: 11/13/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The usefulness of endoscopic procedures for chronic subdural hematoma (CSDH) has been described, but the indications in patients of very advanced age have not been analyzed. The aim of this study was to evaluate the feasibility, safety, and usefulness of introduction of an endoscopic procedure for such patients. METHODS We retrospectively analyzed the data of 540 CSDHs treated by burr-hole surgery with endoscopic examination. The safety of the endoscopic procedure was assessed according to postoperative complications, morbidity, and mortality. The outcome was evaluated by statistical comparison among 4 different age-groups, and the recurrence rate and risk factors for recurrence was investigated in patients of very advanced age. RESULTS Postoperative complications occurred in 7 cases (1.5%). The 6-month morbidity and mortality were 13.5% and 4.5%. No complications, morbidity, or mortality associated with the additional endoscopic procedure occurred even in patients of very advanced age. The endoscopic features of trabecular structures and residual septa separating the cavity were also risk factors for recurrence in patients of very advanced age. Releasing of the septa showed the possibility of decreasing the risk of recurrence to 6.6% in patients aged ≥85 years as well as in younger patients. There were some inevitable problems such as prolongation of the surgical time and inadequate endoscopic surgical skill. CONCLUSIONS An endoscopic procedure for CSDH can be safely indicated and useful even in patients aged ≥85 years. However, clinicians should carefully select the patients based on clinical information associated with risk factors for recurrence.
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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
| | - Kenji Fukuda
- 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
| | - 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
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Moledina S, Shanmuganathan M, Pathak S, Simon A. Spontaneous subdural haematoma in a patient with a total artificial heart on warfarin. BMJ Case Rep 2019; 12:12/9/e230519. [PMID: 31488446 DOI: 10.1136/bcr-2019-230519] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We present the unusual case of a middle-aged woman who developed a spontaneous subdural haematoma (SSH) while on oral anticoagulation therapy for a total artificial heart (TAH). Headache was followed by paraesthesia and numbness of the left hand. The diagnosis was made from a CT scan. Symptoms resolved with conservative management and careful control of anticoagulation. In this case report, the risk factors and pathophysiology behind this condition are explored. TAHs in their own entity are a rare phenomenon. Coupled with the highly unusual presentation of an SSH in which only a few cases have been documented, we hope to highlight the management of such a difficult case. After navigating this complication, we were able to successfully bridge this patient to a heart transplant 26 days after the SSH.
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Affiliation(s)
- Saadiq Moledina
- Gastroenterology, Royal Free London NHS Foundation Trust, London, UK.,Department of Cardiovascular Sciences, Royal Brompton and Harefield NHS Foundation Trust, London
| | | | - Suraj Pathak
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, Glenfield Hospital, Leicester, UK
| | - Andre Simon
- Cardiothoracic Medicine, Royal Brompton and Harefield NHS Foundation Trust, London, UK
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Karakaya Z, Saritas A, Yeşim Akyol P, Esad Topal F, Payza U, Bilgin S. Evaluation of Chronic Subdural Hematoma Volume Calculated via Cavalieri’s Principle. KONURALP TIP DERGISI 2019. [DOI: 10.18521/ktd.469173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Holl DC, Volovici V, Dirven CMF, van Kooten F, Miah IP, Jellema K, Peul WC, van der Gaag NA, Kho KH, den Hertog HM, Dammers R, Lingsma HF. Corticosteroid treatment compared with surgery in chronic subdural hematoma: a systematic review and meta-analysis. Acta Neurochir (Wien) 2019; 161:1231-1242. [PMID: 30972566 DOI: 10.1007/s00701-019-03881-w] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 03/20/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND There is an ongoing debate on the role of corticosteroids in the treatment of chronic subdural hematoma (CSDH). This study aims to evaluate the effectiveness of corticosteroids for the treatment of CSDH compared to surgery. METHOD A systematic search was performed in relevant databases up to January 2019 to identify RCTs or observational studies that compared at least two of three treatment modalities: the use of corticosteroids as a monotherapy (C), corticosteroids as an adjunct to surgery (CS), and surgery alone (S). Outcome measures were good neurological outcome, need for reintervention, mortality, and complications. Effect estimates were pooled and presented as relative risk (RR) with 95% confidence interval (95%CI). RESULTS Of 796 initially identified studies, 7 were included in the meta-analysis. Risk of bias was generally high. There were no differences in good neurological outcome between treatment modalities. The need for reintervention varied between 4 and 58% in C, 4-12% in CS, and 7-26% in S. The need for reintervention was lower in CS compared with C (RR 3.34 [95% CI 1.53-7.29]; p < 0.01) and lower in CS compared with S (RR 0.44 [95% CI 0.27-0.72]; p < 0.01). Mortality varied between 0 and 4% in C, 0-13% in CS, and 0-44% in S. Mortality was lower in CS compared with S (RR 0.39 [95% CI 0.25-0.63]; p < 0.01). There were no differences in complications between treatment modalities. CONCLUSIONS This meta-analysis suggests that the addition of corticosteroids to surgery might be effective in the treatment of CSDH. However, the results must be interpreted with caution in light of the serious risk of bias of the included studies. This study stresses the need for large randomized trials to investigate the use of corticosteroids in the management of CSDH.
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Affiliation(s)
- Dana C Holl
- Department of Neurosurgery, Erasmus MC Stroke Centre, Erasmus Medical Centre, 2040, 3000 CA Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands.
| | - Victor Volovici
- Department of Neurosurgery, Erasmus MC Stroke Centre, Erasmus Medical Centre, 2040, 3000 CA Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
- Department of Public Health and Medical Decision Making, Erasmus MC, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Clemens M F Dirven
- Department of Neurosurgery, Erasmus MC Stroke Centre, Erasmus Medical Centre, 2040, 3000 CA Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Fop van Kooten
- Department of Neurology, Erasmus MC Stroke Centre, Erasmus Medical Centre, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Ishita P Miah
- Department of Neurology, Haaglanden Medical Centre, Postbus 432, 2501 CK, The Hague, The Netherlands
| | - Korné Jellema
- Department of Neurology, Haaglanden Medical Centre, Postbus 432, 2501 CK, The Hague, The Netherlands
| | - Wilco C Peul
- Department of Neurosurgery, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Niels A van der Gaag
- Department of Neurosurgery, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Haaglanden MC and Haga Teaching Hospital, Postbus 432, 2501 CK, The Hague, The Netherlands
| | - Kuan H Kho
- Department of Neurosurgery, Medisch Spectrum Twente, Koningsplein 1, 7512 KZ, Enschede, The Netherlands
| | - Heleen M den Hertog
- Department of Neurology, Isala Hospital Zwolle, Dokter van Heesweg 2, 8025 AB, Zwolle, The Netherlands
| | - Ruben Dammers
- Department of Neurosurgery, Erasmus MC Stroke Centre, Erasmus Medical Centre, 2040, 3000 CA Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Hester F Lingsma
- Department of Public Health and Medical Decision Making, Erasmus MC, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
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Bah AB, Souaré IS, Diawara S, Boubane D, Saran KO. [Surgical treatment of chronic subdural hematoma in Guinea: Analysis of 22 cases at the Kipe hospital of Conakry]. Neurochirurgie 2019; 65:83-88. [PMID: 30953620 DOI: 10.1016/j.neuchi.2019.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 03/06/2019] [Accepted: 03/20/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE We report the results of surgical treatment of chronic subdural hematoma in the Kipe Hospital in Conakry, Guinea, for the period July 2012 to November 2015. MATERIAL AND METHOD Clinical, radiological and therapeutic data from 22 cases were collected retrospectively and analyzed, with a mean follow-up of 61.6 days. Univariate analysis screened for factors for neurological outcome on the Markwalder Grading Scale (MGS; 0=normal to 4=coma). RESULTS Male-female sex ratio was 2.6:1. Mean age at diagnosis was 71.09±8 years, with peak incidence of CSDH in the 60-79 age group. Traumatic brain injury was identified as causal in 40.9% of cases. Burrhole trepanation was used in 86.36% of cases, under local anesthesia in 76%, and with postoperative drainage in all cases. No recurrences were recorded. At follow-up, mean postoperative MGS was 0.59 (up from 3.08 preoperatively); 54.54% of patients had normal neurological examination (grade 0). Age 60-79 years, time to diagnosis>12 weeks and preoperative MGS≥3 had significant negative impact on outcome (respective P-values: 0.03, 0.001, 0.001). CONCLUSION Our data were similar to those of the literature, but with longer time to diagnosis and poorer initial clinical status, with negative impact on clinical progression.
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Affiliation(s)
- A B Bah
- Service de neurochirurgie, hôpital de l'amitié sino-guinéenne de Kipé, Conakry, Guinée; Service de chirurgie générale, CHU Ignace Deen, Kaloum, Conakry, Guinée.
| | - I S Souaré
- Service de neurochirurgie, hôpital de l'amitié sino-guinéenne de Kipé, Conakry, Guinée
| | - S Diawara
- Service de neurochirurgie, hôpital de l'amitié sino-guinéenne de Kipé, Conakry, Guinée; Service de neurochirurgie, CHU Donka, Donka, Conakry, Guinée
| | - D Boubane
- Service de neurochirurgie, hôpital de l'amitié sino-guinéenne de Kipé, Conakry, Guinée
| | - K O Saran
- Service de neurochirurgie, hôpital de l'amitié sino-guinéenne de Kipé, Conakry, Guinée
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Kamenova M, Mueller C, Coslovsky M, Guzman R, Mariani L, Soleman J. Low-dose aspirin and burr-hole drainage of chronic subdural hematoma: study protocol for a randomized controlled study. Trials 2019; 20:70. [PMID: 30665464 PMCID: PMC6341728 DOI: 10.1186/s13063-018-3064-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 11/20/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Low-dose acetylsalicylic acid (ASA) in patients with chronic subdural hematoma (cSDH) represents a significant neurosurgical challenge. While continuation of ASA during the perioperative phase might increase recurrence and bleeding rates, discontinuation increases the risk of thromboembolic events. The aim of this study is to compare the postoperative recurrence and cardiovascular complication rates of patients undergoing burr-hole trepanation for cSDH with and without discontinuation of ASA. METHODS In this prospective randomized, placebo-controlled, double-blinded study we include all patients undergoing burr-hole drainage of cSDH who are under ASA treatment. The patients are randomized into two groups, one receiving ASA and the other placebo perioperatively. The study primarily seeks to compare the rate of recurrent events under ASA to that under placebo treatment. Secondary objectives are thromboembolic event rate, perioperative blood loss, postoperative anemia, intra- and postoperative blood transfusion rate, and clinical outcome. DISCUSSION To date, there is no evidence-based consensus on how to manage patients undergoing burr-hole drainage for cSDH who are under ASA treatment. Therefore, the decision to maintain or interrupt ASA treatment is based mostly on the surgeons' preference. A randomized placebo-controlled study for this frequent question is urgently needed in order to provide class I evidence for the best possible treatment of this large group of patients. TRIAL REGISTRATION ClinicalTrials.gov: NCT03120182 . Initial Release: 19.04.2017. STUDY PROTOCOL V2_23.02.2017.
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Affiliation(s)
- Maria Kamenova
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4053 CH, Basel, Switzerland.
| | - Christian Mueller
- Department of Cardiology, University Hospital of Basel, Petersgraben 4, 4031 CH, Basel, Switzerland
| | - Michael Coslovsky
- Clinical Trial Unit University Hospital of Basel, Spitalstrasse 12, 4031 CH, Basel, Switzerland
| | - Raphael Guzman
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4053 CH, Basel, Switzerland
| | - Luigi Mariani
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4053 CH, Basel, Switzerland
| | - Jehuda Soleman
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4053 CH, Basel, Switzerland
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Wang H, Zhang M, Zheng H, Xia X, Luo K, Guo F, Qian C. The effects of antithrombotic drugs on the recurrence and mortality in patients with chronic subdural hematoma: A meta-analysis. Medicine (Baltimore) 2019; 98:e13972. [PMID: 30608437 PMCID: PMC6344112 DOI: 10.1097/md.0000000000013972] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES Chronic subdural hematoma (cSDH) is a common neurological disorder in elderly and the immediate outcome of surgery is satisfied. The high reoperation rate hinders the long-term effect of surgery and the risk factor is still unclear. Some researchers reported that high recurrence rate is related to the antithrombotic (AT) drugs, which is commonly used to prevent diseases in elderly patients. In this article, we conducted a meta-analysis to determine whether AT agents increase the risk of recurrence and mortality in patients with cSDH. METHODS The human case-control or randomized controlled trial (RCT) studies regarding the association of cSDH and AT were systematically identified through online databases (PubMed, Cochrane, Web of Science, Elsevier Science Direct, and Springer Link). Inclusion and exclusion criteria were defined for the eligible studies. The fixed-effects model was performed when homogeneity was indicated. RESULTS This meta-analysis included 24 studies. AT drugs significantly increased the risk of recurrence in patients with cSDH (odds ratio (OR) of 1.30, 95% confidence interval (CI), 1.11-1.52, P = .001). Further analysis demonstrated that both anticoagulation (OR of 1.41, 95% CI, 1.10-1.81, P = .006) and antiplatelet (OR of 1.23, 95% CI, 1.01-1.49, P = .03) had higher risk of recurrence, but no difference was found between them (OR of 0.80, 95% CI, 0.58-1.09, P = .16). However AT drugs did not increase the risk of mortality for patients with cSDH (OR of 1.08, 95% CI, 0.61-1.92, P = .78). CONCLUSION AT treatment is an important risk factor of recurrence in patients with cSDH in spite of similar mortality rate. When and how to resume AT drugs is still unclear, more well-designed prospective researches are needed on this issue. CORE TIP High recurrence is an important factor against the long-term outcome of surgery in patients with cSDH, the use of AT drugs is a potential risk factor. In this study we found that the use of AT drugs increased the risk of recurrence rather than mortality. Anticoagulation and antiplatelet showed no difference in causing cSDH recurrence.
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Affiliation(s)
- Han Wang
- Geriatrics Department, Tongde Hospital of Zhejiang Province, Hangzhou
| | - Meibiao Zhang
- Neurosurgery Department, Lanxi People's Hospital, Lanxi
| | - He Zheng
- Neurosurgery Department, Lanxi People's Hospital, Lanxi
| | - Xiaolong Xia
- Neurosurgery Department, Lanxi People's Hospital, Lanxi
| | - Kehui Luo
- Neurosurgery Department, Lanxi People's Hospital, Lanxi
| | - Feng Guo
- Neurosurgery Department, Lanxi People's Hospital, Lanxi
| | - Cong Qian
- Neurosurgery Department, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
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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.
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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
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Effects of Pre-Existing Comorbidities on Outcomes in Patients with Chronic Subdural Hematoma. World Neurosurg 2018; 122:e924-e932. [PMID: 30408607 DOI: 10.1016/j.wneu.2018.10.176] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 10/23/2018] [Accepted: 10/26/2018] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The number of patients with chronic subdural hematoma (CSDH) showing comorbidities and/or impaired activities of daily living (ADL) before the onset of CSDH has increased with the recent aging of society. The purposes of this study were to evaluate ADL worsening by comparing premorbid ADL and ADL at discharge and to investigate the effects of pre-existing comorbidity-related clinical factors on the outcomes. METHODS A total of 570 patients with CSDH admitted from 2006 to 2016 were studied retrospectively. Clinical factors, including pre-existing comorbidities, related to outcomes were identified by multivariate analysis. A variation of the modified Rankin Scale (mRS) using 5 united categories of mRS scores 0/1, 2, 3/4, 5, and dead was used for evaluation of ADL. RESULTS Of 570 patients, 390 (68.4%) had pre-existing comorbidities and 120 (21.1%) showed premorbid impaired ADL (mRS scores 2 and worse). Considering pre-existing impaired ADL, ADL deteriorated after CSDH in 92 patients (16.1%), whereas ADL impairment at discharge was found in 173 patients (30.4%). Comorbidities related to ADL deterioration on multivariate analysis were hemodialysis and chronic heart failure. Antithrombotic use for cardiovascular diseases was a predictor of acute-on-chronic subdural hematoma, which was the sole common predictor for ADL deterioration and the occurrence of surgical complications. CONCLUSIONS In patients with CSDH, pre-existing comorbidity-linked factors related to outcomes were hemodialysis, chronic heart failure, and antithrombotic use. Patients with acute-on-chronic subdural hematoma with these factors should be regarded as a high-risk group.
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Lee KS, Yoon SM, Oh JS, Oh HJ, Shim JJ, Doh JW. Causes and Trauma Apportionment Score of Chronic Subdural Hematoma. Korean J Neurotrauma 2018; 14:61-67. [PMID: 30402420 PMCID: PMC6218349 DOI: 10.13004/kjnt.2018.14.2.61] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Revised: 08/22/2018] [Accepted: 08/29/2018] [Indexed: 11/24/2022] Open
Abstract
Objective The pathophysiology of chronic subdural hematoma (CSH) is not yet clear. Trauma alone is not sufficient to result in CSH in young individuals, while a trivial injury can result in CSH in older adults. Although the causality and apportionment of trauma are important issues in CSH, especially in terms of insurance, it is too obscure to solve all struggles. Methods There are three key factors for producing CSH. First, CSH necessitates a potential subdural reservoir. Other important precipitating factors are trauma and coagulopathy. However, these factors are not sufficient to cause CSH development. The trauma apportionment score (TAS) can be used to compare the relative importance of these three factors. Here, we applied the TAS to 239 consecutive cases of CSH. We retrospectively obtained the patients' history and laboratory results from their medical records. Results The TAS ranged from −5 to 5. The most common score was 0. If we defined the cause of CSH as being combined when the TAS was 0, then the cause was combined in 30 cases (12.6%). If we extended the criteria for a combined cause from 0 to −1 to 1, the cause was combined in 107 cases (44.8%). Regardless of the criteria used, traumatic CSHs were more common than were spontaneous CSHs. Spontaneous CSHs were more common in older than in younger patients (p<0.01, Fisher's exact test). Conclusion The TAS is a useful tool for differentiating the causality of CSH.
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Affiliation(s)
- Kyeong-Seok Lee
- Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Seok-Mann Yoon
- Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Jae-Sang Oh
- Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Hyuk-Jin Oh
- Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Jae-Jun Shim
- Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Jae-Won Doh
- Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
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Ryu SM, Yeon JY, Kong DS, Hong SC. Risk of Recurrent Chronic Subdural Hematoma Associated with Early Warfarin Resumption: A Matched Cohort Study. World Neurosurg 2018; 120:e855-e862. [PMID: 30189302 DOI: 10.1016/j.wneu.2018.08.177] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Revised: 08/23/2018] [Accepted: 08/23/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Studies on resuming anticoagulation after burr-hole drainage for chronic subdural hematoma (CSDH) are limited. To evaluate the safety for early warfarin resumption after burr-hole drainage, we conducted a retrospective matched cohort study. METHODS Between January 2008 and April 2015, 36 patients with warfarin-related unilateral CSDH and 151 patients with ordinary unilateral CSDH were enrolled in this study. Patients taking warfarin were managed homogeneously according to the study protocol, and the usual dosage of warfarin was resumed within 2 or 3 days of burr-hole drainage to reach a target international normalized ratio (INR) of 2.1. The primary outcome, defined as recurrent CSDH requiring repeated burr-hole drainage within 3 months of the initial surgery, was compared between the two groups. RESULTS The primary outcome was observed in 4 (11%) of the 36 patients taking warfarin and in 18 (12%) of the 151 ordinary patients. After propensity score matching, the primary outcome was observed in 3 of 33 patients (9%) in the matched warfarin cohort and 11 of 74 patients (15%) in the matched ordinary cohort. When the results were analyzed using the generalized estimating equation, no significant difference was observed in the rate of recurrent CSDH between the 2 groups (P = 0.411). In addition, we found that recurrent CSDH was not related to postoperative international normalized ratio levels (P = 0.332). CONCLUSIONS There was no definitive association between postoperative early warfarin resumption and the recurrence rate of CSDH. Patients with warfarin-related CSDH and a strong indication for anticoagulation can be managed by resuming warfarin within 3 days of burr-hole drainage.
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Affiliation(s)
- Sung Mo Ryu
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Je Young Yeon
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
| | - Doo-Sik Kong
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Seung-Chyul Hong
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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türk O, yaldız C, ceylan D. Kronik Subdural Hematom: 67 Hastanın Radyolojisi, Hematololojik Parametreleri ve Cerrahi Sonuçları. MUSTAFA KEMAL ÜNIVERSITESI TIP DERGISI 2018. [DOI: 10.17944/mkutfd.423487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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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.
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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
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You W, Zhu Y, Wang Y, Liu W, Wang H, Wen L, Yang X. Prevalence of and risk factors for recurrence of chronic subdural hematoma. Acta Neurochir (Wien) 2018. [PMID: 29532258 DOI: 10.1007/s00701-018-3513-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Chronic subdural hematoma (CSDH) is a common disease in neurosurgical practice with substantial recurrence rate. We aimed to estimate recurrence rate of CSDH and to identify risk factors for CSDH recurrence. METHODS We retrospectively studied consecutive cases with CSDH and performed surgical therapy in our hospital. Univariate and multivariate logistic regression analyses were performed to identify factors associated with recurrence of CSDH. RESULTS A total of 226 patients with CSDH were included; 34 patients recurred after surgery with a recurrence rate of 15.0%. Univariate analysis showed that the recurrence group had more patients with homogenous hyper-dense hematoma (20.6 vs 6.3%, p = 0.035) and shorter duration of subdural drainage post-surgery (1.2 ± 1.4 vs 1.5 ± 0.9, p = 0.022) than the non-recurrence group. Logistic regression analysis revealed that duration of subdural drainage (OR = 0.66, p = 0.05) and hyper-dense of hematoma (OR = 4.94, p = 0.012) were independent predictors for CSDH recurrence. CONCLUSIONS Homogenous hyper-dense of hematoma and duration of subdural drainage post-surgery were independent predictors for CSDH recurrence; longer duration of postoperative subdural drainage was associated with lower risk of recurrence.
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Affiliation(s)
- Wendong You
- Department of Neurosurgery, First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, Zhejiang Province, 310003, China
| | - Yuanrun Zhu
- Department of Neurosurgery, First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, Zhejiang Province, 310003, China
| | - Yadong Wang
- Department of Neurosurgery, First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, Zhejiang Province, 310003, China
| | - Wenchao Liu
- Department of Neurosurgery, First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, Zhejiang Province, 310003, China
| | - Hao Wang
- Department of Neurosurgery, First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, Zhejiang Province, 310003, China
| | - Liang Wen
- Department of Neurosurgery, First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, Zhejiang Province, 310003, China
| | - Xiaofeng Yang
- Department of Neurosurgery, First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou, Zhejiang Province, 310003, China.
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Scerrati A, Mangiola A, Rigoni F, Olei S, Santantonio M, Trevisi G, Anile C, Cavallo MA, De Bonis P. Do antiplatelet and anticoagulant drugs modify outcome of patients treated for chronic subdural hematoma? Still a controversial issue. J Neurosurg Sci 2018; 65:626-633. [PMID: 29671291 DOI: 10.23736/s0390-5616.18.04311-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Anticoagulants(ACs) and antiplatelet aggregation agents(AAAs) seem to be correlated to a higher incidence of chronic subdural hematoma(CSDH) but whether or not they contribute to its recurrence is debated. Few data are available on clinical outcomes and indications for the management of this therapy are not so well defined. We investigated the role of ACs and AAAs in modifying patients clinical outcomes treated for CSDH, especially for re-bleedings. METHODS This retrospective study, enrolled patients treated for CSDH. Patients characteristics were recorded including drugs used (antiplatelet/anticoagulant) and clinical conditions (Modified Rankin Scale-mRS) upon admission. Patients underwent surgery(burrhole vs minicraniectomy) with subdural drainage positioning. Clinical/radiological follow-ups were performed at one and six months. Chi square/Fisher exact test were used to compare variables and stepwise backward logistic regression analysis was used for defining their impact on complications, risk of re-bleeding and reoperation. RESULTS 230 patients (45 on ACs, 76 on AAAs and 9 on both)were enrolled. Higher mRS scores were significantly associated with a higher risk of general complications (OR = 3.78, CI 95% 1.66- 8.62, p=0.002), higher risk of rebleeding (OR =15.82, CI 95% 4.33-57.90, p <0.001) and re- operation (OR=11.39, CI 95% 3.35-37.56, p<0.0001). No statistically significant association was found between AAAs or ACs and complications or re- bleedings or risk of reoperation. CONCLUSIONS AAAs and ACs alone do not seem to worsen the clinical outcome or increase re- bleedings. mRS may be a predicting factor, since patients with higher scores showed a worse outcome and an increased risk of re-bleeding, general complications and reoperation.
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Affiliation(s)
- Alba Scerrati
- Neurosurgery, Sant'Anna University Hospital, Ferrara, Italy -
| | - Annunziato Mangiola
- Neurosurgery, Chieti University G. D'Annunzio, Santo Spirito Hospital, Pescara, Italy.,Neurotrauma, Catholic University School of Medicine, Rome, Italy
| | | | - Simone Olei
- Neurosurgery, Sant'Anna University Hospital, Ferrara, Italy
| | | | - Gianluca Trevisi
- Neurotrauma, Catholic University School of Medicine, Rome, Italy
| | - Carmelo Anile
- Neurotrauma, Catholic University School of Medicine, Rome, Italy
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Influence of antithrombotic agents on recurrence rate and clinical outcome in patients operated for chronic subdural hematoma. Neurocirugia (Astur) 2018; 29:86-92. [DOI: 10.1016/j.neucir.2017.09.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 09/06/2017] [Accepted: 09/12/2017] [Indexed: 11/23/2022]
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Evidence based diagnosis and management of chronic subdural hematoma: A review of the literature. J Clin Neurosci 2018; 50:7-15. [PMID: 29428263 DOI: 10.1016/j.jocn.2018.01.050] [Citation(s) in RCA: 105] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Accepted: 01/08/2018] [Indexed: 11/23/2022]
Abstract
Chronic subdural hematomas are encapsulated blood collections within the dural border cells with characteristic outer "neomembranes". Affected patients are more often male and typically above the age of 70. Imaging shows crescentic layering of fluid in the subdural space on a non-contrast computed tomography (CT) scan, best appreciated on sagittal or coronal reformats. Initial medical management involves reversing anticoagulant/antiplatelet therapies, and often initiation of anti-epileptic drugs (AEDs). Operative interventions, such as twist-drill craniostomy (TDC), burr-hole craniostomy (BHC), and craniotomy are indicated if imaging implies compression (maximum fluid collection thickness >1 cm) or the patient is symptomatic. The effectiveness of various surgical techniques remains poorly characterized, with sparse level 1 evidence, variable outcome measures, and various surgical techniques. Postoperatively, subdural drains can decrease recurrence and sequential compression devices can decrease embolic complications, while measures such as early mobilization and re-initiation of anticoagulation need further study. Non-operative management, including steroid therapy, etizolam, tranexamic acid, and angiotensin converting enzyme inhibitors (ACEI) also remain poorly studied. Recurrent hemorrhages are a major complication affecting around 10-20% of patients, and therefore close follow-up is essential.
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Takahashi S, Yamauchi T, Yamamura T, Ogishima T, Arai T. Proposal of Treatment Strategies for Bilateral Chronic Subdural Hematoma Based on Laterality of Treated Hematoma. Asian J Neurosurg 2018; 13:1134-1139. [PMID: 30459882 PMCID: PMC6208213 DOI: 10.4103/ajns.ajns_124_18] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Background: Chronic subdural hematoma (CSDH) is a disorder that is commonly seen in routine neurosurgery. Although risk factors for recurrence have been studied, the findings are inconsistent. Furthermore, bilateral CSDHs are operated unilaterally or bilaterally depending on symptoms or hematoma volume. Although there are cases in which hematomas on nonoperated side in unilaterally operated bilateral CSDHs requiring for additional operation, little have been studied on the effect of the surgical selection. The purpose of this study is to identify risk factors for recurrence in operated hematomas and additional operation in nonoperated hematomas and improve surgical strategy. Materials and Methods: We retrospectively reviewed patients who underwent surgery in our facility for bilateral CSDHs between January 2011 and December 2016. Univariate and multivariate analyses were performed to examine the relationship between recurrence or requirement for additional operation and clinical and radiological variables. Results: Recurrence was observed significantly more frequent for operated hematomas when hematoma type was separated type as reported previously. In unilaterally operated bilateral CSDHs, there were 22 hematomas on nonoperated side, and five hematomas required an additional operation after the first hospitalization. Increased volume of hematoma on the nonoperated side was the risk factors for additional operation (P = 0.022). Receiver operating characteristic (ROC) curve revealed that requirement for additional operation significantly increased when hematoma volume enlarged to approximately 44 cm3 or greater 1 day after operation. Conclusions: In unilaterally operated bilateral CSDHs, when hematoma volume on nonoperated side increased 1 day after the last operation, additional operation in the early stage is considerable to prevent re-hospitalization and deterioration of activities of daily living.
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Affiliation(s)
- Satoru Takahashi
- Department of Neurosurgery, Soka Municipal Hospital, Soka, Saitama, Japan
| | - Takahiro Yamauchi
- Department of Neurosurgery, Soka Municipal Hospital, Soka, Saitama, Japan
| | - Toshihiro Yamamura
- Department of Neurosurgery, Soka Municipal Hospital, Soka, Saitama, Japan
| | - Takahiro Ogishima
- Department of Neurosurgery, Soka Municipal Hospital, Soka, Saitama, Japan
| | - Toshinari Arai
- Department of Neurosurgery, Soka Municipal Hospital, Soka, Saitama, Japan
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Toi H, Kinoshita K, Hirai S, Takai H, Hara K, Matsushita N, Matsubara S, Otani M, Muramatsu K, Matsuda S, Fushimi K, Uno M. Present epidemiology of chronic subdural hematoma in Japan: analysis of 63,358 cases recorded in a national administrative database. J Neurosurg 2018; 128:222-228. [DOI: 10.3171/2016.9.jns16623] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEAging of the population may lead to epidemiological changes with respect to chronic subdural hematoma (CSDH). The objectives of this study were to elucidate the current epidemiology and changing trends of CSDH in Japan. The authors analyzed patient information based on reports using a Japanese administrative database associated with the diagnosis procedure combination (DPC) system.METHODSThis study included patients with newly diagnosed CSDH who were treated in hospitals participating in the DPC system. The authors collected data from the administrative database on the following clinical and demographic characteristics: patient age, sex, and level of consciousness on admission; treatment procedure; and outcome at discharge.RESULTSA total of 63,358 patients with newly diagnosed CSDH and treated in 1750 DPC participation hospitals were included in this study. Analysis according to patient age showed that the most common age range for these patients was the 9th decade of life (in their 80s). More than half of patients 70 years old or older presented with some kind of disturbance of consciousness. Functional outcomes at discharge were good in 71.6% (modified Rankin Scale [mRS] score 0–2) of cases and poor in 28.4% (mRS score 3–6). The percentage of poor outcomes tended to be higher in elderly patients. Approximately 40% of patients 90 years old or older could not be discharged to home. The overall recurrence rate for CSDH was 13.1%.CONCLUSIONSThis study shows a chronological change in the age distribution of CSDH among Japanese patients, which may be affecting the prognosis of this condition. In the aging population of contemporary Japan, patients in their 80s were affected more often than patients in other age categories, and approximately 30% of patients with CSDH required some help at discharge. CSDH thus may no longer have as good a prognosis as had been thought.
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Affiliation(s)
- Hiroyuki Toi
- 1Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Okayama
| | - Keita Kinoshita
- 1Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Okayama
| | - Satoshi Hirai
- 1Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Okayama
| | - Hiroki Takai
- 1Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Okayama
| | - Keijiro Hara
- 1Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Okayama
| | | | - Shunji Matsubara
- 1Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Okayama
| | - Makoto Otani
- 2Department of Preventive Medicine and Community Health, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Fukuoka; and
| | - Keiji Muramatsu
- 2Department of Preventive Medicine and Community Health, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Fukuoka; and
| | - Shinya Matsuda
- 2Department of Preventive Medicine and Community Health, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Fukuoka; and
| | - Kiyohide Fushimi
- 3Department of Health Policy and Informatics, Tokyo Medical and Dental University, Tokyo, Japan
| | - Masaaki Uno
- 1Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Okayama
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Influence of Postoperative Thrombosis Prophylaxis on the Recurrence of Chronic Subdural Hematoma After Burr-Hole Drainage. Crit Care Med 2018; 46:e26-e32. [DOI: 10.1097/ccm.0000000000002804] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Soleman J, Kamenova M, Guzman R, Mariani L. The Management of Patients with Chronic Subdural Hematoma Treated with Low-Dose Acetylsalicylic Acid: An International Survey of Practice. World Neurosurg 2017; 107:778-788. [DOI: 10.1016/j.wneu.2017.08.065] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 08/08/2017] [Accepted: 08/10/2017] [Indexed: 11/15/2022]
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Kamenova M, Lutz K, Schaedelin S, Fandino J, Mariani L, Soleman J. Does Early Resumption of Low-Dose Aspirin After Evacuation of Chronic Subdural Hematoma With Burr-Hole Drainage Lead to Higher Recurrence Rates? Neurosurgery 2017; 79:715-721. [PMID: 27538015 DOI: 10.1227/neu.0000000000001393] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Antiplatelet therapy in patients with chronic subdural hematoma (cSDH) presents significant neurosurgical challenges. Given the lack of guidelines regarding perioperative management with antiplatelet therapy, it is difficult to balance the patient's increased cardiovascular risk and prevalence of cSDH. OBJECTIVE To better understand the risk and recurrence rates related to resuming low-dose acetylsalicylic acid (ASA) by evaluating our patients' resumption of low-dose ASA at various times after burr-hole drainage of the hematoma. METHODS In our retrospective study, 140 consecutive patients taking low-dose ASA undergoing surgical evacuation of cSDH were included. Data included baseline characteristics and rates of recurrence, morbidity, and mortality. A multivariate logistic regression model analyzed the association between ASA resumption time and recurrence rates. RESULTS No statistically significant association was observed between early postoperative resumption of low-dose ASA and recurrence of cSDH (odds ratio, 1.01; 95% confidence interval, 1.001-1.022; P = .06). Corresponding odds ratios and risk differences for restarting ASA treatment on postoperative days 1, 7, 14, 21, 28, 35, or 42 were estimated at 1.53 and 5.9%, 1.42 and 5.1%, 1.33 and 4.1%, 1.23 and 3.2%, 1.15 and 2.2%, 1.07 and 1.1%, and 1.01 and 0.2%, respectively (P > .05). Cardiovascular event rates, surgical morbidity, and mortality did not significantly differ between patients with or without ASA therapy. CONCLUSION Given the few published studies regarding ASA use in cranial neurosurgery, our findings elucidate one issue, showing comparable recurrence rates with early or late resumption of low-dose ASA after burr-hole evacuation of cSDH. ABBREVIATIONS ASA, acetylsalicylic acidCAD, coronary artery diseaseCI, confidence intervalcSDH, chronic subdural hematomaGCS, Glasgow Coma ScalemRS, modified Rankin ScaleOR, odds ratioRD, risk difference.
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Affiliation(s)
- Maria Kamenova
- ‡Department of Neurosurgery and¶Clinical Trial Unit, University Hospital of Basel, Basel, Switzerland;§Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
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Kim SU, Lee DH, Kim YI, Yang SH, Sung JH, Cho CB. Predictive Factors for Recurrence after Burr-Hole Craniostomy of Chronic Subdural Hematoma. J Korean Neurosurg Soc 2017; 60:701-709. [PMID: 29142630 PMCID: PMC5678055 DOI: 10.3340/jkns.2016.1010.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 12/20/2016] [Accepted: 03/10/2017] [Indexed: 12/15/2022] Open
Abstract
Objective Chronic subdural hematoma is a common and relatively benign disease. However, recurrence is common after surgical treatment, and the recurrence rate varies from 5% to 33%. The aim of this study was to investigate the predictive factors for recurrence of chronic subdural hematoma. Methods We analyzed data from 248 patients with chronic subdural hematoma who were treated by burr-hole craniostomy with a closed drainage system for hematoma evacuation in this five-year retrospective study. Results Thirty-one (12.6%) patients underwent re-operation for recurrence of chronic subdural hematoma. Univariate analysis revealed that anticoagulation (p=0.0279), headache (p=0.0323), and preoperative midline shifting (p=0.0321) showed significant differences with respect to recurrent chronic subdural hematoma. We performed a multivariate logistic regression analysis and found that diabetes mellitus (odds ratio [OR], 2.618; 95% confidence interval [CI], 1.0899-6.2898; p=0.0314), anticoagulation (OR, 6.739; 95% CI, 1.1287-40.2369; p=0.0364), headache (OR, 2.951; 95% CI, 1.1464-7.5964; p=0.0249), and preoperative midline shifting (OR, 1.0838; 95% CI, 1.0040-1.1699; p=0.0391) were independent predictive factors for recurrence of chronic subdural hematoma. Conclusion We showed that diabetes mellitus, anticoagulation, headache, and preoperative midline shifting were independent predictors of recurrence of chronic subdural hematoma.
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Affiliation(s)
- Sang Uk Kim
- Department of Neurosurgery, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
| | - Dong Hoon Lee
- Department of Neurosurgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Young Il Kim
- Department of Neurosurgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Seung Ho Yang
- Department of Neurosurgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Jae Hoon Sung
- Department of Neurosurgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Chul Bum Cho
- Department of Neurosurgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
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Choi YH, Han SR, Lee CH, Choi CY, Sohn MJ, Lee CH. Delayed Burr Hole Surgery in Patients with Acute Subdural Hematoma: Clinical Analysis. J Korean Neurosurg Soc 2017; 60:717-722. [PMID: 29142632 PMCID: PMC5678051 DOI: 10.3340/jkns.2017.0404.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 07/05/2017] [Accepted: 08/12/2017] [Indexed: 11/27/2022] Open
Abstract
Objective To evaluate the effectiveness and efficacy of delayed burr hole surgery in relation to the reduction of postoperative subdural hematoma (SDH) volume in patients with acute SDH. Methods We retrospectively analyzed patients with acute SDH who received delayed burr hole surgery at our institute. Age, sex, Glasgow coma scale, maximal SDH thickness, volume of SDH, midline shifts, hounsfield unit (HU), and medical history of anticoagulant agent usage were recorded. Outcome measures were delayed operation day, reduction of SDH volume after operation, and the Glasgow outcome scale (GOS) score at discharge. The patients were divided two groups according to the post-operative reduction of volume of SDH (≥50%, group A; <50%, group B). We also analyzed variables and differences between two groups. Results Eighteen patients were available for this analysis. The mean delayed of surgery was 13.9±7.5 days. Maximal thickness of SDH was changed from 10.0±3.5 mm to 12.2±3.7 mm. Volume of SDH was changed from 38.7±28.0 mL to 42.6±29.6 mL. Midline shifts were changed from 5.8±3.3 mm to 6.6±3.3 mm. HU were changed from 66.4±11.2 to 53.2±20.6. Post-operative reduction of SDH volume was 52.1±21.1%. Eleven patients (61%) had a discharge GOS score of 1 (good recovery). Ten patients (56%) were enrolled in group A. Midline shifting was greater in group A than in group B (7.4±3.3 vs. 3.0±2.4 mm; p<0.02). The delay of surgery was shorter for group A than group B (9.2±2.3 vs. 19.8±7.7 days; p<0.0008). Conclusion Among well selected patients, delayed burr hole surgery in patients with acute SDH may be effective for reduction of SDH volume. Further studies will be necessary to establish the effectiveness and safety of delayed burr hole surgery in patients with acute SDH.
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Affiliation(s)
- Yoon Heuck Choi
- Department of Neurosurgery, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Seong Rok Han
- Department of Neurosurgery, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Chang Hyun Lee
- Department of Neurosurgery, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Chan Young Choi
- Department of Neurosurgery, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Moon Jun Sohn
- Department of Neurosurgery, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Chae Heuck Lee
- Department of Neurosurgery, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
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Yamada SM, Tomita Y, Murakami H, Nakane M, Yamada S, Murakami M, Hoya K, Nakagomi T, Tamura A, Matsuno A. Headache in patients with chronic subdural hematoma: analysis in 1080 patients. Neurosurg Rev 2017; 41:549-556. [PMID: 28815322 DOI: 10.1007/s10143-017-0889-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 07/13/2017] [Accepted: 07/31/2017] [Indexed: 11/26/2022]
Abstract
Headache is a major symptom in chronic subdural hematoma (CSDH) patients. However, some CSDH patients do not complain headache although the hematoma is thick with definite midline shift. This clinical study was performed to identify the mechanism of headache in CSDH patients. We compiled clinical data of 1080 surgically treated CSDH patients (711 males and 369 females), and in 54 cases, the pressure of hematoma was measured during burr hole surgery using a glass-stick manometer. Headache was recognized in 22.6% of patients, while nausea or vomit suggesting increased intracranial pressure was detected in only 3.0%. Ophthalmological examination was performed in 238 patients, and papilledema was identified in only one patient (0.4%). The mean age of patients with headache (59.8 ± 16.9 years) was significantly younger than that of those without (75.7 ± 11.2 years) (P < 0.01). In 54 cases, the mean hematoma pressure was not significantly different between patients with (17.1 ± 6.2 mmH2O) and without (18.4 ± 7.2 mmH2O) headache (P > 0.10). Hematoma thickness was significantly greater in patients without headache (P < 0.01), but the ratio of midline shift to hematoma thickness was significantly greater in patients with headache (P < 0.01). In our results, the status of increased intracranial pressure was rare in CSDH patients, and high hematoma pressure was not a cause of headache. Midline shift was the most influenced factor for headache in our study, and based on the results, the authors consider that the potential cause of headache in CSDH might be stretching or twisting of the pain-sensitive meninges and meningeal arteries or veins.
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Affiliation(s)
- Shoko M Yamada
- Department of Neurosurgery, Teikyo University Mizonokuchi Hospital, 5-1-1 Futago, Takatsu-ku, Kawasaki, Kanagawa, 213-8507, Japan.
| | - Yusuke Tomita
- Department of Neurosurgery, Teikyo University Mizonokuchi Hospital, 5-1-1 Futago, Takatsu-ku, Kawasaki, Kanagawa, 213-8507, Japan
| | - Hideki Murakami
- Department of Neurosurgery, Teikyo University Mizonokuchi Hospital, 5-1-1 Futago, Takatsu-ku, Kawasaki, Kanagawa, 213-8507, Japan
| | - Makoto Nakane
- Department of Neurosurgery, Teikyo University Mizonokuchi Hospital, 5-1-1 Futago, Takatsu-ku, Kawasaki, Kanagawa, 213-8507, Japan
| | - So Yamada
- Department of Neurosurgery, Teikyo University Chiba Medical Center, 3426-3 Anesaki, Ichihara-city, Chiba, 299-0111, Japan
| | - Mineko Murakami
- Department of Neurosurgery, Teikyo University Chiba Medical Center, 3426-3 Anesaki, Ichihara-city, Chiba, 299-0111, Japan
| | - Katsumi Hoya
- Department of Neurosurgery, Teikyo University Chiba Medical Center, 3426-3 Anesaki, Ichihara-city, Chiba, 299-0111, Japan
| | - Tadayoshi Nakagomi
- Department of Neurosurgery, Teikyo University Hospital, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8606, Japan
| | - Akira Tamura
- Department of Neurosurgery, Teikyo University Hospital, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8606, Japan
| | - Akira Matsuno
- Department of Neurosurgery, Teikyo University Hospital, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8606, Japan
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Association between antithrombotic drug use before chronic subdural haematoma and outcome after drainage: a systematic review and meta-analysis. Neurosurg Rev 2017; 41:439-445. [PMID: 28550627 DOI: 10.1007/s10143-017-0860-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 05/09/2017] [Indexed: 10/19/2022]
Abstract
In view of their age and vascular co-morbidities, people are often taking an antithrombotic drug when diagnosed with chronic subdural haematoma (CSDH). It is unclear whether antithrombotic use at CSDH diagnosis, or resumption afterwards, is associated with recurrent CSDH or vaso-occlusive events. We systematically reviewed the literature for studies reporting CSDH recurrence or vaso-occlusive events after drainage of CSDH associated with antithrombotic drug use. We searched Medline 1946-2016 and Embase 1974-2016 inclusive for cohort studies reporting the risk of CSDH recurrence or vaso-occlusive events after CSDH associated with antithrombotic (anticoagulant or antiplatelet) drug use. We meta-analysed outcome data using a random effect model and assessed inconsistency between studies using the I-squared (I 2) statistic. We found 20 studies reporting outcome after drainage of CSDH associated with antithrombotic drug use. Before CSDH drainage, 337 (11.5%) of 2941 patients in 12 studies used an anticoagulant drug and 600 (19%) of 3150 patients in 11 studies used an antiplatelet drug. The association between antithrombotic drug use and CSDH recurrence was significant for antiplatelet drug use (relative risk [RR] 1.36, 95% CI 1.05 to 1.75; I 2 = 36.3%), but marginally significant for anticoagulant drug use (RR 1.38 95% CI 1.00-1.91; I 2 = 37.5%). Two studies including 30 patients reported one vaso-occlusive outcome event after CSDH. Antithrombotic drug use at CSDH diagnosis may be associated with post-operative CSDH recurrence. It is unclear whether this is attributable to confounding factors, antithrombotic reversal strategies or antithrombotic drug resumption. Further observational studies and randomised controlled trials of antithrombotic drug resumption are needed.
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Kim E. Embolization Therapy for Refractory Hemorrhage in Patients with Chronic Subdural Hematomas. World Neurosurg 2017; 101:520-527. [DOI: 10.1016/j.wneu.2017.02.070] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Revised: 02/12/2017] [Accepted: 02/15/2017] [Indexed: 10/20/2022]
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