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Matsumoto H, Matsumoto A, Miyata S, Tomogane Y, Minami H, Masuda A, Yamaura I, Yoshida Y, Hirata Y. The Effect of Japanese Herbal Medicines (Kampo) Goreisan and Saireito on the Prevention of Recurrent Chronic Subdural Hematoma: A Prospective Randomized Study. Neurosurgery 2024; 94:80-89. [PMID: 37638721 DOI: 10.1227/neu.0000000000002649] [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: 04/05/2023] [Accepted: 06/22/2023] [Indexed: 08/29/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Chronic subdural hematoma (CSDH) sometimes recurs after surgical treatment and requires reoperation. In Japan, Japanese herbal medicines (Kampo), such as Goreisan and Saireito, have been used as adjunctive therapies to prevent the recurrence of CSDH. However, no prospective randomized study has proven the efficacy of Kampo medicine in all patients. To investigate whether Goreisan and Saireito reduce the postoperative recurrence of CSDH in a prospective randomized study. METHODS Between April 2017 and July 2019, a total of 118 patients who underwent initial burr hole surgery for CSDH were randomly assigned to the following 3 groups: (1) Goreisan for 3 months (Group G), (2) Saireito for 3 months (Group S), and (3) no medication (Group N). The primary end point was symptomatic recurrence within 3 months postoperatively, and the secondary end point was complications associated with the administration of Kampo medicine. RESULTS Among 118 patients, 114 (Group N, n = 39; Group G, n = 37; and Group S, n = 38) were included in our analysis. In this study, byakujutsu (containing Atractylodes rhizome ) Goreisan and Saireito were used, unlike other prospective randomized studies in which sojutsu (containing Atractylodes lancea rhizome) Goreisan was used. The overall recurrence rate was 11.4% (13/114: 10 for Group N, 2 for Group G, and 1 for Group S). The recurrence rate of Group G was significantly lower than that of Group N (5.4% vs 25.6%; P = .043). The recurrence rate of Group S was also significantly lower than that of Group N (2.6% vs 25.6%; P = .02). No patients developed complications associated with the administration of Kampo medicine. CONCLUSION This is the first study to show that Kampo medicine reduced the recurrence rate of CSDH in an overall population. This study demonstrated that byakujutsu Goreisan and Saireito may have favorable effects, unlike other studies, because byakujutsu has stronger anti-inflammatory activity than sojutsu.
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Affiliation(s)
- Hiroaki Matsumoto
- Department of Neurosurgery, Cerebrovascular Research Institute, Eisyokai Yoshida Hospital, Kobe , Hyogo , Japan
| | - Atsushi Matsumoto
- Department of Neurosurgery, Cerebrovascular Research Institute, Eisyokai Yoshida Hospital, Kobe , Hyogo , Japan
| | - Shiro Miyata
- Department of Neurosurgery, Cerebrovascular Research Institute, Eisyokai Yoshida Hospital, Kobe , Hyogo , Japan
| | - Yusuke Tomogane
- Department of Neurosurgery, Cerebrovascular Research Institute, Eisyokai Yoshida Hospital, Kobe , Hyogo , Japan
| | - Hiroaki Minami
- Department of Neurosurgery, Cerebrovascular Research Institute, Eisyokai Yoshida Hospital, Kobe , Hyogo , Japan
| | - Atsushi Masuda
- Department of Neurosurgery, Cerebrovascular Research Institute, Eisyokai Yoshida Hospital, Kobe , Hyogo , Japan
| | - Ikuya Yamaura
- Department of Neurosurgery, Cerebrovascular Research Institute, Eisyokai Yoshida Hospital, Kobe , Hyogo , Japan
| | - Yasuhisa Yoshida
- Department of Neurosurgery, Cerebrovascular Research Institute, Eisyokai Yoshida Hospital, Kobe , Hyogo , Japan
| | - Yutaka Hirata
- Department of Neurology, Cerebrovascular Research Institute, Eisyokai Yoshida Hospital, Kobe , Hyogo , Japan
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Fujisawa N, Oya S, Yoshida S, Tsuchiya T, Nakamura T, Indo M, Matsui T. A Prospective Randomized Study on the Preventive Effect of Japanese Herbal Kampo Medicine Goreisan for Recurrence of Chronic Subdural Hematoma. Neurol Med Chir (Tokyo) 2020; 61:12-20. [PMID: 33208583 PMCID: PMC7812313 DOI: 10.2176/nmc.oa.2020-0287] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Although the recurrence of chronic subdural hematoma (CSDH) after surgical treatment significantly affects the patients' quality of life, the recurrence rate has not improved in decades. Goreisan, a Japanese herbal Kampo medicine, promotes the hydragogue effect and has been empirically used in the treatment of CSDH in Japan. We conducted a prospective randomized study to investigate whether Goreisan treatment decreases the recurrence rate of CSDH. Between March 2013 and December 2018, a total of 224 patients who underwent initial burr hole surgery for CSDH were randomly assigned to receive Goreisan for 3 months (Group G) or no medication (Group N). The primary endpoint was symptomatic recurrence within 3 months postoperatively, and the secondary endpoint was complications, including the adverse effects of Goreisan. Of 224 randomized patients, 208 were included in the final analysis (104 in Group G and 104 in Group N). The overall recurrence rate was 9.1% (19/208). The recurrence rate of Group G was lower than that of Group N (5.8% vs 12.5%, P = 0.09), but the difference was not statistically significant. However, a significant preventive effect of Goreisan was found in 145 patients with high-risk computed tomography (CT) features, namely, homogeneous and separated types (5.6% vs 17.6%, P = 0.04). Although the present study did not prove the beneficial effect of Goreisan treatment, it suggested the importance of selecting patients with an increased risk of recurrence. A subset of patients whose hematoma showed homogeneous and separated patterns on CT image might benefit from Goreisan treatment.
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Affiliation(s)
- Naoaki Fujisawa
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University
| | - Soichi Oya
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University
| | - Shinsuke Yoshida
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University
| | - Tsukasa Tsuchiya
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University
| | - Takumi Nakamura
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University
| | - Masahiro Indo
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University
| | - Toru Matsui
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University
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Katayama K, Matsuda N, Kakuta K, Naraoka M, Takemura A, Hasegawa S, Akasaka K, Shimamura N, Itoh K, Asano K, Konno H, Ohkuma H. The Effect of Goreisan on the Prevention of Chronic Subdural Hematoma Recurrence: Multi-Center Randomized Controlled Study. J Neurotrauma 2019; 35:1537-1542. [PMID: 29444611 DOI: 10.1089/neu.2017.5407] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The relatively high rate of post-operative recurrence in the treatment of chronic subdural hematoma (CSDH) is a significant problem. Goreisan is an herbal medicine that exhibits a hydragogue effect by inhibiting the expression of aquaporins, and its efficacy in preventing post-operative CSDH recurrence has been suggested by several case trials. This multi-center prospective randomized controlled trial was performed to investigate the preventative effect of goreisan on post-operative CSDH recurrence. Patients with symptomatic CSDH over 60 years old undergoing burr hole surgery were enrolled in this study. The patients were randomly allocated to the control group or the goreisan group, in which oral administration of goreisan (7.5 g daily) was continued for 12 weeks. The primary end-point was the post-operative recurrence rate at 12 weeks and the secondary end-point was hematoma volume reduction rates on computed tomography scan at 12 weeks. The analyses were performed not only on patients of all ages older than 60 years, but also on patients divided into those over or under 75 years old. One hundred and eighty patients were followed and analyzed (the control group, n = 88; the goreisan group, n = 92). The recurrence rates considering patients of all ages and patients under 75 years old were relatively low in the goreisan group but without a significant difference. The hematoma volume reduction rates showed no significant difference. Based on the results of the present study, a larger-scale study including more cases is necessary in future to confirm the efficacy of goreisan.
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Affiliation(s)
- Kosuke Katayama
- 1 Department of Neurosurgery, Hirosaki University Graduate School of Medicine , Aomori, Japan
| | - Naoya Matsuda
- 1 Department of Neurosurgery, Hirosaki University Graduate School of Medicine , Aomori, Japan
| | - Kiyohide Kakuta
- 1 Department of Neurosurgery, Hirosaki University Graduate School of Medicine , Aomori, Japan
| | - Masato Naraoka
- 1 Department of Neurosurgery, Hirosaki University Graduate School of Medicine , Aomori, Japan
| | | | - Seiko Hasegawa
- 3 Department of Neurosurgery, Kuroishi Hopital , Aomori, Japan
| | - Kenichi Akasaka
- 4 Department of Neurosurgery, Towada Central Hopital , Aomori, Japan
| | - Norihito Shimamura
- 1 Department of Neurosurgery, Hirosaki University Graduate School of Medicine , Aomori, Japan
| | - Katsuhiro Itoh
- 1 Department of Neurosurgery, Hirosaki University Graduate School of Medicine , Aomori, Japan
| | - Kenichiro Asano
- 1 Department of Neurosurgery, Hirosaki University Graduate School of Medicine , Aomori, Japan
| | - Hiromu Konno
- 5 Department of Neurosurgery, Hachinohe Japanese Red Cross Hospital , Aomori, Japan
| | - Hiroki Ohkuma
- 1 Department of Neurosurgery, Hirosaki University Graduate School of Medicine , Aomori, Japan
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Arai M, Inaba R. [A case of tuberculous meningitis with pleural effusion as a manifestation of a paradoxical reaction during anti-tuberculosis therapy]. Rinsho Shinkeigaku 2019; 59:541-544. [PMID: 31341131 DOI: 10.5692/clinicalneurol.cn-001309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We present a case of tuberculous meningitis (TBM), wherein pleural effusion developed as a manifestation of paradoxical reaction during anti-tuberculosis therapy. An 87-year-old diabetic man was referred to our clinic for fever and impaired consciousness. He did not obey vocal commands. No ocular motor deficit, facial palsy, or limb weakness was observed. He had hyponatremia due to inappropriate antidiuresis. Examination of the cerebrospinal fluid revealed lymphocytosis and high adenosine deaminase (ADA) activity, suggestive of TBM. He was treated with isoniazid, rifampicin, and pyrazinamide, after which his symptoms quickly resolved. Lymphocyte count, ADA activity, and protein concentration in the cerebrospinal fluid decreased. However, approximately 30 days after the initiation of therapy, he developed mild hypoxemia. A chest CT scan revealed pleural effusion. The pleural fluid was exudate with elevated ADA activity, which was consistent with tuberculous pleural effusion. Shortly after the use of a herbal medicine, Goreisan extract, hyponatremia and hypoproteinemia improved, and the pleural effusion was reduced. Approximately one-third of patients with TBM are reported to develop a paradoxical reaction, such as tuberculoma, hydrocephalus, and optochiasmatic and spinal arachnoiditis. The present case suggests that extra-central nervous system manifestations, including pleural effusion, should be considered when treating TBM.
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Affiliation(s)
- Motomi Arai
- Department of Neurology, Seirei Mikatahara General Hospital
| | - Ryunosuke Inaba
- Department of Respiratory Medicine, Seirei Mikatahara General Hospital
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Kwon S, Jin C, Cho KH. Oreongsan, an herbal medicine prescription developed as a new alternative treatment in patients with chronic subdural hematoma: a narrative review. Integr Med Res 2018; 8:26-30. [PMID: 30705821 PMCID: PMC6348234 DOI: 10.1016/j.imr.2018.11.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 11/13/2018] [Accepted: 11/20/2018] [Indexed: 12/19/2022] Open
Abstract
An herbal medicine prescription, Oreongsan (ORS), which is composed of Polyporus, Alismatis Rhizoma, Atractylodis Rhizoma, Poria (Hoelen), and Cinnamomi Cortex Spissus, has been used as treatment in patients with various symptoms such as thirst, diminished urination, edema, hangover, and diarrhea. ORS is the representative prescription of the ’inducing diuresis’ (isu) effect, which traditionally means the effect of controlling the water balance. Advancement of modern science has enabled the determination of the action mechanism of herbal medicine complexes. As a result, ORS has been used in the treatment of patients with chronic subdural hematoma (CSDH), representing a novel indication. ORS inhibits the upregulation of aquaporin-4, which is involved in the development of brain edema in the central nervous system. Both aquaporin-1 and aquaporin-4 are expressed in the outer membrane of the CSDH; through its effect as aquaporin-4 inhibitor, ORS prevents the inflow of fluid into the hematoma, thereby preventing the development and recurrence of hematoma. In this study, we reviewed the relationship between the inducing diuresis effect of ORS and aquaporin, conservative treatment approach in patients with CSDH, and the prevention of recurrence in patients undergoing combined burr hole surgery and treatment with ORS.
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Affiliation(s)
- Seungwon Kwon
- Department of Cardiology and Neurology, College of Korean Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Chul Jin
- Department of Cardiology and Neurology, College of Korean Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Ki-Ho Cho
- Department of Cardiology and Neurology, College of Korean Medicine, Kyung Hee University, Seoul, Republic of Korea
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Sahyouni R, Goshtasbi K, Mahmoodi A, Tran DK, Chen JW. Chronic Subdural Hematoma: A Perspective on Subdural Membranes and Dementia. World Neurosurg 2017; 108:954-958. [PMID: 28935547 PMCID: PMC5705282 DOI: 10.1016/j.wneu.2017.09.063] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 09/07/2017] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To review the complex pathogenesis of the subdural membrane and the link between head trauma, dementia, and dural lymphatics. METHODS A thorough literature search of published English-language articles was performed using PubMed, Ovid, and Cochrane databases. RESULTS Chronic subdural hematoma (cSDH) is a common intracranial pathology and a leading cause of reversible dementia. cSDH is projected to affect at least 60,000 new individuals in the United States annually by 2030. This condition can result from mild to moderate head trauma that leads to hemorrhaging in the dura-arachnoid interface. The short-term and long-term effects of cSDH and the subdural membrane on the pathogenesis of dementia and the newly discovered dural lymphatics is a topic of increasing importance. CONCLUSIONS Further research into the possible link between traumatic brain injury and cSDH in particular and dural lymphatics and intracranial fluid dynamics is warranted.
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Affiliation(s)
- Ronald Sahyouni
- University of California, Irvine, School of Medicine, Irvine, California, USA; Department of Biomedical Engineering, University of California, Irvine, Samueli School of Engineering, Irvine, California, USA
| | - Khodayar Goshtasbi
- University of California, Irvine, School of Medicine, Irvine, California, USA
| | - Amin Mahmoodi
- Department of Neurological Surgery, University of California, Irvine, Irvine, California, USA
| | - Diem Kieu Tran
- Department of Neurological Surgery, University of California, Irvine, Irvine, California, USA
| | - Jefferson W Chen
- Department of Neurological Surgery, University of California, Irvine, Irvine, California, USA.
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Edlmann E, Giorgi-Coll S, Whitfield PC, Carpenter KLH, Hutchinson PJ. Pathophysiology of chronic subdural haematoma: inflammation, angiogenesis and implications for pharmacotherapy. J Neuroinflammation 2017; 14:108. [PMID: 28558815 PMCID: PMC5450087 DOI: 10.1186/s12974-017-0881-y] [Citation(s) in RCA: 313] [Impact Index Per Article: 44.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 05/15/2017] [Indexed: 02/08/2023] Open
Abstract
Chronic subdural haematoma (CSDH) is an encapsulated collection of blood and fluid on the surface of the brain. Historically considered a result of head trauma, recent evidence suggests there are more complex processes involved. Trauma may be absent or very minor and does not explain the progressive, chronic course of the condition. This review focuses on several key processes involved in CSDH development: angiogenesis, fibrinolysis and inflammation. The characteristic membrane surrounding the CSDH has been identified as a source of fluid exudation and haemorrhage. Angiogenic stimuli lead to the creation of fragile blood vessels within membrane walls, whilst fibrinolytic processes prevent clot formation resulting in continued haemorrhage. An abundance of inflammatory cells and markers have been identified within the membranes and subdural fluid and are likely to contribute to propagating an inflammatory response which stimulates ongoing membrane growth and fluid accumulation. Currently, the mainstay of treatment for CSDH is surgical drainage, which has associated risks of recurrence requiring repeat surgery. Understanding of the underlying pathophysiological processes has been applied to developing potential drug treatments. Ongoing research is needed to identify if these therapies are successful in controlling the inflammatory and angiogenic disease processes leading to control and resolution of CSDH.
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Affiliation(s)
- Ellie Edlmann
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Box 167, Cambridge Biomedical Campus, Cambridge, CB2 0QQ UK
| | - Susan Giorgi-Coll
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Box 167, Cambridge Biomedical Campus, Cambridge, CB2 0QQ UK
| | - Peter C. Whitfield
- Southwest Neurosurgical Centre, Plymouth Hospitals NHS Trust, Plymouth, PL6 8DH UK
| | - Keri L. H. Carpenter
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Box 167, Cambridge Biomedical Campus, Cambridge, CB2 0QQ UK
| | - Peter J. Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Box 167, Cambridge Biomedical Campus, Cambridge, CB2 0QQ UK
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Abstract
Chronic subdural hematoma (CSDH) is one of the most common neurosurgical conditions. There is lack of uniformity in the treatment of CSDH amongst surgeons in terms of various treatment strategies. Clinical presentation may vary from no symptoms to unconsciousness. CSDH is usually diagnosed by contrast-enhanced computed tomography scan. Magnetic resonance imaging (MRI) scan is more sensitive in the diagnosis of bilateral isodense CSDH, multiple loculations, intrahematoma membranes, fresh bleeding, hemolysis, and the size of capsule. Contrast-enhanced CT or MRI could detect associated primary or metastatic dural diseases. Although definite history of trauma could be obtained in a majority of cases, some cases may be secondary to coagulation defect, intracranial hypotension, use of anticoagulants and antiplatelet drugs, etc., Recurrent bleeding, increased exudates from outer membrane, and cerebrospinal fluid entrapment have been implicated in the enlargement of CSDH. Burr-hole evacuation is the treatment of choice for an uncomplicated CSDH. Most of the recent trials favor the use of drain to reduce recurrence rate. Craniotomy and twist drill craniostomy also play a role in the management. Dural biopsy should be taken, especially in recurrence and thick outer membrane. Nonsurgical management is reserved for asymptomatic or high operative risk patients. The steroids and angiotensin converting enzyme inhibitors may also play a role in the management. Single management strategy is not appropriate for all the cases of CSDH. Better understanding of the nature of the pathology, rational selection of an ideal treatment strategy for an individual patient, and identification of the merits and limitations of different surgical techniques could help in improving the prognosis.
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Affiliation(s)
- Yad R Yadav
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Vijay Parihar
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Hemant Namdev
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Jitin Bajaj
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
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