The influence of preoperative anticoagulation on outcome and quality of life after surgical treatment of chronic subdural hematoma

Initial experience using middle meningeal artery embolisation for patients with recurrent and high-recurrence-risk chronic subdural haematoma

Recurrence rates following surgical management of chronic subdural haematoma (CSDH) range from 5 to 33 %. There is growing evidence which suggests middle meningeal artery embolisation (MMAe) may reduce recurrence rates when used as surgical adjunct or standalone treatment. In this study we described our experience of this new procedure in the our UK institution. Patients with recurrent CSDH or CSDH at high risk of recurrence were selected for MMAe on a case-by-case basis following MDT discussion. A departmental database was used to identify patients treated. 26 CSDH were embolised in 20 patients; 9 CSDH were de-novo and 17 were recurrent. 10/26 CSDH were treated with MMAe only. No procedural mortality, access site or thrombo-embolic complications occurred. One patient experienced symptomatic collection growth 12 h following MMAe and required surgical drainage. 15 (75 %) of patients were living at home at follow-up (mean 14 months). On imaging follow-up 15/18 showed CSDH volume reduction or resolution, 1/18 remained stable requiring no further treatment, 2/18 patients suffered recurrent CSDH requiring treatment. In both recurrent cases incomplete embolisation was noted on procedural imaging (posterior division of MMA not embolised). Persistent posterior MMA division filling was significantly associated with collection recurrence (p = 0.002). Our results suggest MMAe as a stand-alone or adjuvant therapy can be performed safely in a UK neuroscience setting and is associated with high rates of symptomatic CSDH size reduction or resolution in problematic CSDH that have either recurred or are prone to recurrence.

Middle meningeal artery embolization reduces recurrence following surgery for septated chronic subdural hematomas

BACKGROUND

Septated chronic subdural hematomas (cSDH) have high rates of recurrence despite surgical evacuation. Middle meningeal artery embolization (MMAE) has emerged as a promising adjuvant for secondary prevention, yet its efficacy remains ill-defined.

METHODS

This is a retrospective review of septated cSDH cases treated at our institution. The surgery-only group was derived from cases performed before 2018, and the surgery+MMAE group was derived from cases performed 2018 or later. The primary outcome was reoperation rate. Secondary outcomes were recurrence, change in hematoma thickness, and midline shift.

RESULTS

A total of 34 cSDHs in 28 patients (surgery+MMAE) and 95 cSDHs in 83 patients (surgery-only) met the inclusion criteria. No significant difference in baseline characteristics between groups was identified. The reoperation rate was significantly higher in the surgery-only group (n = 16, 16.8%) compared with the surgery+MMAE cohort (n = 0, 0.0%) (p=0.006). A reduced incidence of recurrence (p=0.011) was also seen in the surgery+MMAE group.

CONCLUSIONS

MMAE for septated cSDH was found to be highly effective in preventing recurrence and reoperation. MMAE is an adjunct to surgical evacuation may be of particular benefit in this patient cohort.

Embolization of the middle meningeal artery for the prevention of chronic subdural hematoma recurrence in high-risk patients: a randomized controlled trial-the EMPROTECT study protocol

BACKGROUND

Middle meningeal artery (MMA) embolization has been proposed as a treatment of chronic subdural hematoma (CSDH). The benefit of the procedure has yet to be demonstrated in a randomized controlled trial. We aim to assess the efficacy of MMA embolization in reducing the risk of CSDH recurrence 6 months after burr-hole surgery compared with standard medical treatment in patients at high risk of postoperative recurrence.

METHODS

The EMPROTECT trial is a multicenter open label randomized controlled trial (RCT) involving 12 French centers. Adult patients (≥18 years) operated for CSDH recurrence or for a first episode with a predefined recurrence risk factor are randomized 1:1 to receive either MMA embolization within 7 days of the burr-hole surgery (experimental group) or standard medical care (control group). The number of patients to be included is 342.

RESULTS

The primary outcome is the rate of CSDH recurrence at 6 months. Secondary outcomes include the rate of repeated surgery for a homolateral CSDH recurrence during the 6-month follow-up period, the rate of disability and dependency at 1 and 6 months, defined by a modified Rankin Scale (mRS) score ≥4, mortality at 1 and 6 months, total cumulative duration of hospital stay during the 6-month follow-up period, directly or indirectly related to the CSDH and embolization procedure-related complication rates.

CONCLUSIONS

The EMPROTECT trial is the first RCT evaluating the benefit of MMA embolization as a surgical adjunct for the prevention of CSDH recurrence. If positive, this trial will have a significant impact on patient care.

TRIAL REGISTRATION NUMBER

NCT04372147.

A Linear Regression Equation for Predicting the Residual Volume of Chronic Subdural Hematoma 1 Week After Surgery

Objective

The outcome of chronic subdural hematoma (CSDH) is influenced not only by the choice of treatment but also by various baseline characteristics. The main objective of this study is to identify the risk factors that can affect the prognosis of CSDH and develop a regression equation based on these risk factors.

Methods

A total of 212 patients with CSDH were included in the study. We collected clinical data including age, gender, and so on, and radiological data including preoperative hematoma volume (V1), effusion volume 1 day after surgery (V2), gas volume 1 day after surgery (V3), and so on. These were considered independent variables, while residual volume 1 week after surgery (V4) was the dependent variable. Univariate linear regression analysis was performed to identify factors that were significantly related. Subsequently, multivariate linear regression analysis was conducted to determine the relationship between each independent variable and the dependent variable. Multiple linear regression analysis was used to obtain a regression equation predicting V4.

Results

We have found that age (t = 3.109, P = 0.002), aspirin (t = 2.762, P = 0.006), hemostatic agents (haemocoagulase, t = 3.731, P < 0.001; vitamin K, t = 2.824, P = 0.005 < 0.05), V2 (t = 8.73, P < 0.001), and V3 (t = 5.968, P < 0.001) are significantly associated with V4. Furthermore, we have developed a regression equation that can predict this volume with CSDH. The fit of the model is robust with an R-squared value of 65.2% > 50%.

Conclusion

Age, aspirin, hemostatic agent, V2, and V3 are significantly associated with V4. We developed a regression equation to predict this volume with CSDH.

Middle Meningeal Artery Embolization Versus Conventional Management for Patients With Chronic Subdural Hematoma: A Systematic Review and Meta-Analysis

BACKGROUND

The results from studies that compare middle meningeal artery (MMA) embolization vs conventional management for patients with chronic subdural hematoma are varied.

OBJECTIVE

To conduct a systematic review and meta-analysis on studies that compared MMA embolization vs conventional management.

METHODS

Medline, PubMed, and Embase databases were searched. Primary outcomes were treatment failure and surgical rescue; secondary outcomes were complications, follow-up modified Rankin scale > 2, mortality, complete hematoma resolution, and length of hospital stay (day). The certainty of the evidence was determined using the GRADE approach.

RESULTS

Nine studies yielding 1523 patients were enrolled, of which 337 (22.2%) and 1186 (77.8%) patients received MMA embolization and conventional management, respectively. MMA embolization was superior to conventional management for treatment failure (relative risk [RR] = 0.34 [0.14-0.82], P = .02), surgical rescue (RR = 0.33 [0.14-0.77], P = .01), and complete hematoma resolution (RR = 2.01 [1.10-3.68], P = .02). There was no difference between the 2 groups for complications (RR = 0.93 [0.63-1.37], P = .72), follow-up modified Rankin scale >2 (RR = 0.78 [0.449-1.25], P = .31), mortality (RR = 1.05 [0.51-2.14], P = .89), and length of hospital stay (mean difference = -0.57 [-2.55, 1.41], P = .57). For MMA embolization, the number needed to treat for treatment failure, surgical rescue, and complete hematoma resolution was 7, 9, and 3, respectively. The certainty of the evidence was moderate to high for primary outcomes and low to moderate for secondary outcomes.

CONCLUSION

MMA embolization decreases treatment failure and the need for surgical rescue without furthering the risk of morbidity and mortality. The authors recommend considering MMA embolization in the chronic subdural hematoma management.

Free-flap reconstruction of the lower limb in octogenarians - A comparative analysis of indications, management, and outcomes

INTRODUCTION

Impaired microcirculation, along with an increase in chronic medical conditions in the geriatric cohort, may favor the development of soft-tissue defects in the lower extremity and equally impair the options for plastic-reconstructive surgery. In particular, outcome analyses in the increasing patient cohort ≥ 80 years (octogenarians) are limited.

METHODS

Setting 80 years as the cutoff, we conducted an age-related outcome analysis of all patients undergoing free-flap reconstruction of the lower extremity from 2014 to 2020, comprising the American Society of Anesthesiologists (ASA) score and Charlson Comorbidity Index (CCI) as the possible outcome predicting factors.

RESULTS

During the study period, a total of 424 free flaps were performed in 385 patients (∅: 54.7 years ± 16.1; range: 9-89), including 19 octogenarians. Compared with the younger patient cohort, there was a significantly higher rate of early flap revision (p = 0.023) and flap loss (p = 0.028). Furthermore, the mean length of hospital (60.6 ± 37.6 vs. 51.1 ± 37.0) and intensive care unit/intermediate care stay (6.5 ± 15.0 vs. 3.5 ± 8.5) was extended (n.s.). The ASA score presented an independent predictor for major surgical [odds ratio (OR): 1.66; p = 0.041) and medical complications (OR: 3.97; p<0.001). Neither the CCI nor the ASA served as an independent predictor for total flap loss.

CONCLUSION

Free-flap reconstruction of the lower extremity in octogenarians is associated with a higher risk of flap revision and flap loss. Considering the prolonged immobilization associated with increased morbidity following limb amputation, it presents still a reasonable option to achieve limb salvage in carefully chosen patients. An adequate tool to predict the success of free-flap survival is still unavailable.

Predictors of Subsequent Intervention After Middle Meningeal Artery Embolization for Treatment of Subdural Hematoma: A Nationwide Analysis

BACKGROUND

Middle meningeal artery (MMA) embolization has recently emerged as an effective technique to treat subdural hematomas (SDHs). Studies to date have been limited, largely, to single-center studies with limited follow-up and have not assessed subsequent surgical interventions and factors associated with these interventions.

OBJECTIVE

To evaluate rates of retreatment for SDH after MMA embolization and patient-specific factors that may be important predictors for these interventions.

METHODS

Using an all-payer claims database, Mariner, patients who underwent MMA embolization between January 2010 and October 2020 after the diagnosis of SDH were identified. Rates of post-MMA embolization surgical interventions, including craniotomy and burr hole drainage, were accessed within 5 years following. Patient-specific contributors to the rates of these interventions were studied using Gaussian logistic regression models.

RESULTS

A total of 322 patients were included. Of this cohort, 55 (17.1%) required subsequent intervention within 5 years, with 36 (11.2%) receiving burr hole evacuation and 19 (5.9%) receiving craniotomy. Factor Xa inhibitor use was independently associated with subsequent interventions after MMA embolization procedures (odds ratio: 1.20 [95% CI: 1.02-1.40]). Of the other patient factors evaluated, including age, sex, comorbidity status, and use of vitamin K antagonists, antiplatelets, and factor Xa inhibitors, none were found to be significantly associated with future interventions.

CONCLUSION

Although previous literature has shown MMA embolization to be safe and successful in preventing recurrent SDH, patients undergoing this procedure still carry a risk of future interventions. Patients taking factor Xa inhibitors are at especially high risk of subsequent intervention after MMA embolization.

Effect of long-term anticoagulant therapy on the outcome of chronic subdural hematoma: a propensity score-matched analysis

OBJECTIVE

Chronic subdural hematomas (cSDHs) are particularly common in older adults who have increased risk of falls and the conditions that require anticoagulants (ACs). In such cases, clinicians are often left with the dilemma of co-managing the cSDH and the ongoing need for ACs.

METHODS

Patients who underwent surgical management for cSDH at the authors' institution between January 2006 and June 2022 were identified. Propensity score-matched analysis was used to obtain a balance in patients who were on ACs before the procedure versus those who were not, and in patients who were on ACs postprocedure versus those who were not. Length of hospitalization, periprocedural complications, reintervention rate during the same admission, rebleeding risk, and reintervention rates after discharge were compared.

RESULTS

In total, 104 patients were on long-term ACs before the procedure, whereas 372 were not. After matching, 55 pairs were included in the analysis. Postprocedure, 74 patients were started on long-term ACs; the rest were not. A total of 49 patients in each group were then included in the analysis after matching. Comparing the preprocedure AC group with the non-AC group, no significant differences were found in length of hospitalization (8.5 ± 6.7 days vs 8.1 ± 7.7 days, p = 0.75), periprocedural complications (7.3% vs 7.3%, p > 0.99), or reintervention during the same admission (1.8% vs 5.5%, p = 0.31). In the comparison of postprocedure AC and non-AC groups, no significant differences were seen in recurrence rate (8.2% vs 14.3%, p = 0.52), reintervention rate after discharge (4.1% vs 14.3%, p = 0.16), or disability (i.e., mRS ≤ 2; 83.7% vs 89.8%, p = 0.55).

CONCLUSIONS

Being treated with long-term ACs before cSDH procedures does not affect length of hospitalization, periprocedural complications, or reintervention during the same admission. Similarly, administration of long-term ACs after a procedure for cSDH does not increase rebleeding risk or reintervention rate. Patients who are on long-term ACs can have similar interventions to those who are not on ACs. In addition, it is safe to restart patients on AC agents in a 7- to 14-day window after admission for cSDH with or without acute/subacute components.

Predictors of recurrence of chronic subdural haematoma in a cohort study of patients presenting in a sub-Saharan African teaching hospital

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.

Trends and Outcomes of Primary, Rescue, and Adjunct Middle Meningeal Artery Embolization for Chronic Subdural Hematomas

BACKGROUND

Middle meningeal artery embolization (MMAE) is an effective minimally invasive treatment for chronic subdural hematomas (cSDHs). The authors investigated outcomes of primary, adjunct, and rescue MMAE and primary surgery for the treatment of cSDH using a large-scale national database.

METHODS

A retrospective study of all patients who underwent MMAE and/or surgery to treat cSDH was performed using the TriNetX Analytics Network. Primary MMAE was compared with adjunct and rescue MMAE and primary surgery. Primary outcomes included headache, facial weakness, mortality, and treatment failure, within 6 months.

RESULTS

A total of 4274 patients with cSDH met the inclusion criteria. Of these, 209 (4.9%) were treated with primary MMAE, 4050 (94.8%) were treated with primary surgery, 15 (0.35%) were treated using MMAE as an adjunct therapy, and 18 (0.42%) were treated using MMAE as a rescue following a failed surgical intervention. There were no significant differences in headache, facial weakness, and mortality between the groups. Patients who underwent primary MMAE had a significantly higher Charlson comorbidity index (P < 0.0001) than those who underwent primary surgery. The need for surgical rescue was not significantly different between primary MMAE, adjunct MMAE, and rescue MMAE (P > 0.05). Additionally, patients with primary surgery had significantly higher treatment failure than those with primary MMAE (odds ratio = 2.11, 95% confidence interval = 1.11-4.01, P = 0.020).

CONCLUSIONS

This analysis suggests no significant difference in the need for surgical rescue, complication, or mortality between primary MMAE, adjunct MMAE, and rescue MMAE. Additionally, primary MMAE is associated with a significantly lower need for surgical rescue than primary surgery.

The effect of antithrombotic therapy on the recurrence and outcome of chronic subdural hematoma after burr-hole craniostomy in a population-based cohort

PURPOSE

To study the effect of antithrombotic therapy (ATT) on the outcome of operatively treated chronic subdural hematomas (CSDH).

METHODS

A retrospective population-based cohort study from Eastern Finland including all adult patients who underwent a burr-hole craniostomy (BHC) for CSDH during 2016 and 2017. The follow-up time for recurrence was 6 months and for mortality 3 years.

RESULTS

A total of 301 CSDH patients were included in the study. ATT (antithrombotic therapy; antiplatelet or anticoagulant medication) was used by 164 patients (54.5%) at the time of diagnosis. The hematoma was bilateral in 102 patients (33.9%). Forty-seven patients (15.8%) encountered hematoma recurrence. Bilateral CSDHs required reoperations more often than unilateral hematomas (12.6% vs. 22.0%; p = 0.036) regardless of the primary operation (uni- or bilateral). A bivariate logistic regression analysis showed that bilateral hematoma (OR 1.918; 95% CI 1.013-3.630; p = 0.045) and male gender (OR 2.363; 95% CI 1.089-5.128; p = 0.030) independently predicted hematoma recurrence. The overall three-year mortality was 27.9%. The use of ATT was not associated with CSDH recurrence, and the length of the temporary postoperative ATT discontinuation did not correlate with the rate of thromboembolic events.

CONCLUSIONS

ATT did not affect CSDH recurrence in our study population, and the duration of the temporary postoperative ATT discontinuation was not associated with the rate of thromboembolic complications. Male gender and bilateral hematomas were more frequently associated with recurrences.

Use of the Subdural Hematoma in the Elderly (SHE) Score to Predict 30-Day Mortality After Chronic Subdural Hematoma Evacuation

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.

Efficacy of the Direct Aspiration-Irrigation Maneuver for the Treatment of Chronic Subdural Hematoma: A Single Hospital's Experience

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.

Impact of time to resumption of antithrombotic therapy on outcomes after surgical evacuation of chronic subdural hematoma: A multicenter cohort study

BACKGROUND

The decision to resume antithrombotic therapy after surgical evacuation of chronic subdural hematoma (CSDH) requires judicious weighing of the risk of bleeding against that of thromboembolism. This study aimed to investigate the impact of time to resumption of antithrombotic therapy on outcomes of patients after CSDH drainage.

METHODS

Data were obtained retrospectively from three tertiary hospitals in Singapore from 2010 to 2017. Outcome measures analyzed were CSDH recurrence and any thromboembolic events. Logistic and Cox regression tests were used to identify associations between time to resumption and outcomes.

RESULTS

A total of 621 patients underwent 761 CSDH surgeries. Preoperative antithrombotic therapy was used in 139 patients. 110 (79.1%) were on antiplatelets and 35 (25.2%) were on anticoagulants, with six patients (4.3%) being on both antiplatelet and anticoagulant therapy. Antithrombotic therapy was resumed in 84 patients (60.4%) after the surgery. Median time to resumption was 71 days (IQR 29 - 201). Recurrence requiring reoperation occurred in 15 patients (10.8%), of which 12 had recurrence before and three after resumption. Median time to recurrence was 35 days (IQR 27 - 47, range 4 - 82 days). Recurrence rates were similar between patients that were restarted on antithrombotic therapy before and after 14, 21, 28, 42, 56, 70 and 84 days, respectively. Thromboembolic events occurred in 12 patients (8.6%), of which five had the event prior to restarting antithrombosis.

CONCLUSIONS

Time to antithrombotic resumption did not significantly affect CSDH recurrence. Early resumption of antithrombotic therapy can be safe for patients with a high thromboembolic risk.

Recurrent Spontaneous Bilateral Subdural Hemorrhage as a Consequence of High-Cervical Spontaneous CSF Leak—Lessons for Neurosurgeons

Spontaneous intracranial hypotension (SIH) is rare. It presents as intractable posture headache and is identified by radiological findings. It is confirmed by cerebrospinal fluid (CSF) manometry and myelography, and treatment is carried out with the help of epidural blood patch (EBP) therapy. SIH presenting with spontaneous bilateral recurrent subdural bleeds is uncommon. The cause being a high-spinal CSF leak is even more uncommon! Our patient had recurrent bilateral spontaneous chronic subdural hematomas. Myelographic examination of the spine showed a C1–C2 level leak of CSF. He was taken up for open microsurgery, and the leak was identified and closed with fibrin glue. The patient however deteriorated the next day. An EBP was applied in the lumbar region to cover the myelogram lumbar puncture site. We present a review of literature and an algorithm to detect the elusive CSF leak and effect definitive treatment, either open or EBP, to treat the source of the problem.

Impact of acetylsalicylic acid in patients undergoing cerebral aneurysm surgery - should the neurosurgeon really worry about it?

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.

Middle meningeal artery embolization reduces the post-operative recurrence rate of at-risk chronic subdural hematoma

BACKGROUND

Embolization of the middle meningeal artery (MMA) has emerged as a potential treatment of chronic subdural hematomas (CSDHs).

OBJECTIVE

To evaluate the impact on recurrence rate of postsurgical embolization of CSDH in patients with a higher than average risk of recurrence.

METHODS

A monocentric retrospective study was performed on retrospectively collected data. From March 2018 to December 2019, embolization of the MMA was proposed as an adjunct postoperative treatment after burr-hole surgery in patients operated for a recurrent CSDH or a CSDH with an independent recurrence risk factor, including antiplatelet therapy, full anticoagulation therapy, coagulation disorder, hepatopathy, or chronic alcoholism. Patients who had undergone postoperative embolization were compared with a historic group of patients operated between March 2016 and March 2018, selected based on the same inclusion criteria.

RESULTS

During the study period, 89 patients (with 74 unilateral and 15 bilateral CSDHs) were included and underwent an embolization procedure, leading to 91 out of a total of 104 MMA being embolized (88%). These were compared with 174 patients (138 unilateral and 36 bilateral CSDH) in the historic control group. One major procedure-related adverse event was registered. Four of the 89 patients (4%) required surgery for a CSDH recurrence in the embolization group, significantly less than the 24 of 174 patients (14%) in the control group (OR=0.28, 95% CI 0.07 to 0.86, p=0.02).

CONCLUSIONS

Postsurgical embolization of the MMA may reduce the recurrence rate of CSDHs with a risk factor of recurrence.

Impact of antithrombotic therapy on surgical treatment in patients with chronic subdural hematoma

OBJECTIVE

The effects of antithrombotic therapy on chronic subdural hematoma (CSDH) are controversial. Herein, we investigated the association of antithrombotic therapy with surgical complications and outcomes in patients with CSDH.

METHODS

We retrospectively analyzed 323 consecutive patients with CSDH who underwent single burr-hole craniostomy.

RESULTS

One hundred and eight patients (33%) underwent preoperative antithrombotic therapy. Hemorrhagic and thromboembolic complications were detected in 6 and 8 patients, respectively, which peaked at 3 and 4.5 days after CSDH surgery, respectively. CSDH recurrence was detected in 62 cases, and reoperation was required in 16 cases. Discontinuance of antiplatelet therapy for >2 weeks was significantly associated with thromboembolic complications (43%; p = 0.005). Postoperative use of multiple antithrombotic agents was significantly associated with CSDH recurrence (40%; p = 0.03). Further, earlier recurrence within 2 weeks was significantly associated with the following reoperation (62%; p = 0.006).

CONCLUSIONS

To reduce morbidity and minimize the risk of CSDH reoperation, the optimal timing for resumption of antithrombotic agents is approximately 3 days after CSDH surgery. Postoperative use of multiple antithrombotic agents can increase CSDH recurrence, while earlier recurrence may be a predictor for the following reoperation.

The Effect of Goreisan on the Prevention of Chronic Subdural Hematoma Recurrence: Multi-Center Randomized Controlled Study

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.

Low-dose aspirin and burr-hole drainage of chronic subdural hematoma: study protocol for a randomized controlled study

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.

The effects of antithrombotic drugs on the recurrence and mortality in patients with chronic subdural hematoma: A meta-analysis

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.

Effects of Pre-Existing Comorbidities on Outcomes in Patients with Chronic Subdural Hematoma

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.

Causes and Trauma Apportionment Score of Chronic Subdural Hematoma

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.

The depth of catheter in chronic subdural haematoma: does it matter?

Objective: To investigate the appropriate depth of drainage catheter in the patients with chronic subdural haematoma (CSDH). Methods: We retrospectively analysed the data of 190 patients with CSDH undergoing single parietal burr-hole evacuation and drainage. Results: According to the depth of catheter (DC), 190 patients were divided into three groups: shallow group (DC <4.3 cm), middle group (DC 4.3 ~ 5.4 cm) and deep group (DC > 5.4 cm). During postdischarge 6 months, two, six and nine patients had recurrences in shallow, middle and deep groups, respectively. The recurrence rate in shallow or middle group was significantly lower than that in deep group. No significant difference in preoperative haematoma volume (PHV) was observed in three groups. While the residual subdural space (RSS) in shallow group was significantly smaller than those in the other two groups. The duration of drainage in shallow, middle and deep groups increased successively, and the differences were statistically significant. The total drainage volume (TDV) in shallow group showed no significant difference when compared with the other two groups. Conclusion: The depth of catheter may affect the outcome of CSDH. Inserting drainage catheter shallowly might be a preferred choice in patients with CSDH undergoing burr-hole evacuation and drainage.

Health-related quality of life after adverse bleeding events associated with antithrombotic drug therapy - A systematic review

Little is known about the health-related quality of life (HRQOL) following adverse bleeding events associated with antithrombotic drug therapy. This systematic review assesses the HRQOL of patients who suffered a bleeding event related to antithrombotic drug use. A literature search was performed using PubMed, EMBASE, and the Cochrane Library from inception through June 16, 2017. Studies measuring HRQOL after a bleeding event related to antithrombotic drug therapy for primary or secondary prevention of a thromboembolic event were included. Four studies with a total of 13,209 patients met the inclusion criteria, and of them, 3,649 patients developed a bleeding event. Patients who were included received antithrombotic drugs because of acute myocardial infarction or atrial fibrillation. EQ-5D, SF-36, and GHP MOS-13 were used to measure HRQOL. The follow-up time ranged from 6 to 29 months. Patients who suffered a bleeding event reported worse HRQOL compared to those who did not (EQ-5D - average increase on all domains of 0.09, p-values ranging from <0.001 to 0.003; SF-36 - average decrease on all domains of 21.4, p < 0.001; and GHP MOS-13 score - decrease of 11.9 points, p < 0.05) and an increased health concern (13.4-point increase; p < 0.05). In conclusion, adverse bleeding events occurring because of the use of antithrombotic agents are associated with a clinically relevant lower HRQOL and hence deserve more attention as part of the shared decision-making process between patients and providers. These data should be valuable for facilitating more substantive care and risk discussions regarding potential changes in outcome and rehabilitation.

Value of Routine Preoperative Tests for Coagulation Before Elective Cranial Surgery. Results of an Institutional Audit and a Nationwide Survey of Neurosurgical Centers in Pakistan

BACKGROUND

Routine preoperative blood testing has become a dogma. The general practice is to order preoperative workup as a knee-jerk response rather than individualize it for each patient. The fact that the bleeding brain tends to swell, which coupled with limited options for proximal control, packing, and overall hemostasis, leads to an overemphasis on the preoperative coagulation profile.

MATERIAL AND METHODS

This is a retrospective review of the medical records of patients admitted at Aga Khan University Hospital from January 2010 to December 2015 for an elective craniotomy. The hospital registry was used to identify files for review. Data were collected on a predefined proforma. A nationwide survey was performed, and 30 neurosurgery centers were contacted across Pakistan to confirm the practice of preoperative workup.

RESULTS

The survey revealed that all centers had a similar practice of preoperative workup. This included complete blood count, serum electrolytes, and coagulation profile, including prothrombin time, activated partial thromboplastin time (aPTT), and international normalized ratio (INR). A total of 1800 files were reviewed. Nine (0.5%) patients were found to have deranged clotting profile without any predictive history of clotting derangement; 56% were male and 44% were female. Median age was 32 years with an interquartile range of 27 years. Median aPTT was (40.8 with 20.8 IQR). Median INR was (1.59 with 0.48 IQR). Median blood loss was (400 with 50 IQR). No significant association between coagulation profile (aPTT, INR) and blood loss was found (P = 0.85, r = -0.07).

CONCLUSIONS

We conclude that patients without a history of coagulopathy and normal physical examination do not require routine coagulation screening before elective craniotomy.

Do antiplatelet and anticoagulant drugs modify outcome of patients treated for chronic subdural hematoma? Still a controversial issue

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.

Evidence based diagnosis and management of chronic subdural hematoma: A review of the literature

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.

Role of antithrombotic therapy in the risk of hematoma recurrence and thromboembolism after chronic subdural hematoma evacuation: a population-based consecutive cohort study

Objective

To establish the risk of recurrence in patients with chronic subdural hematoma (cSDH) on antithrombotic treatment (AT, i.e., antiplatelets and anticoagulants). Secondary end points were perioperative morbidity and mortality between groups (AT vs. no-AT group) and exploration if timing of resumption of AT treatment (i.e., prophylactic early vs. late resumption) influenced the occurrence of thromboembolism and hematoma recurrence.

Materials

In a population-based consecutive cohort, we conducted a retrospective review of 763 patients undergoing primary burr hole procedures for cSDH between January 1, 2005, and December 31, 2010, at the Karolinska University Hospital, Stockholm, Sweden. Early AT resumption was ≤30 days and late >30 days after the procedure.

Results

A total of 308/763 (40.4%) cSDH patients were on AT treatment at the time of diagnosis. There was no difference in cSDH recurrence within 3 months (11.0% vs. 12.0%, p = 0.69) nor was there any difference in perioperative mortality (4.0% vs. 2.0%, p = 0.16) between those using AT compared to those who were not. However, perioperative morbidity was more common in the AT group compared to no-AT group (10.7% vs. 5.1%, p = 0.003). Comparing early vs. late AT resumption, there was no difference with respect to recurrence (7.0% vs. 13.9%, p = 0.08), but more thromboembolism in the late AT resumption group (2.0% vs. 7.0%, p < 0.01).

Conclusion

In clinical practice, cSDH patients on AT therapy at the time of diagnosis have similar recurrence rates and mortality compared to those without AT therapy, but with higher morbidity. Early resumption was not associated with more recurrence, but with lower thromboembolic frequency. Early AT resumption seems favorable, and a prospective RCT is needed.

Does Early Resumption of Low-Dose Aspirin After Evacuation of Chronic Subdural Hematoma With Burr-Hole Drainage Lead to Higher Recurrence Rates?

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.

The management and outcome for patients with chronic subdural hematoma: a prospective, multicenter, observational cohort study in the United Kingdom

OBJECTIVE

Symptomatic chronic subdural hematoma (CSDH) will become an increasingly common presentation in neurosurgical practice as the population ages, but quality evidence is still lacking to guide the optimal management for these patients. The British Neurosurgical Trainee Research Collaborative (BNTRC) was established by neurosurgical trainees in 2012 to improve research by combining the efforts of trainees in each of the United Kingdom (UK) and Ireland's neurosurgical units (NSUs). The authors present the first study by the BNTRC that describes current management and outcomes for patients with CSDH throughout the UK and Ireland. This provides a resource both for current clinical practice and future clinical research on CSDH.

METHODS

Data on management and outcomes for patients with CSDH referred to UK and Ireland NSUs were collected prospectively over an 8-month period and audited against criteria predefined from the literature: NSU mortality < 5%, NSU morbidity < 10%, symptomatic recurrence within 60 days requiring repeat surgery < 20%, and unfavorable functional status (modified Rankin Scale score of 4–6) at NSU discharge < 30%.

RESULTS

Data from 1205 patients in 26 NSUs were collected. Bur-hole craniostomy was the most common procedure (89%), and symptomatic recurrence requiring repeat surgery within 60 days was observed in 9% of patients. Criteria on mortality (2%), rate of recurrence (9%), and unfavorable functional outcome (22%) were met, but morbidity was greater than expected (14%). Multivariate analysis demonstrated that failure to insert a drain intraoperatively independently predicted recurrence and unfavorable functional outcome (p = 0.011 and p = 0.048, respectively). Increasing patient age (p < 0.00001), postoperative bed rest (p = 0.019), and use of a single bur hole (p = 0.020) independently predicted unfavorable functional outcomes, but prescription of high-flow oxygen or preoperative use of antiplatelet medications did not.

CONCLUSIONS

This is the largest prospective CSDH study and helps establish national standards. It has confirmed in a real-world setting the effectiveness of placing a subdural drain. This study identified a number of modifiable prognostic factors but questions the necessity of some common aspects of CSDH management, such as enforced postoperative bed rest. Future studies should seek to establish how practitioners can optimize perioperative care of patients with CSDH to reduce morbidity as well as minimize CSDH recurrence. The BNTRC is unique worldwide, conducting multicenter trainee-led research and audits. This study demonstrates that collaborative research networks are powerful tools to interrogate clinical research questions.

Effects of atorvastatin on chronic subdural hematoma: A systematic review

BACKGROUND

The high recurrent rate of chronic subdural hematoma (CSDH) has consistently confused the neurosurgeons, and the role of atorvastatin in the management of CSDH has remained unclear over past decade, and atorvastatin seems to be a safe and cost-effective treatment to CSDH. Therefore, it is necessary to conduct a systematic review to discuss the effect of atorvastatin in CSDH.

METHOD

We searched the PubMed, EMBASE, Cochrane Library, and the China Biology Medicine disc, up to March 2017, for published studies on the effects of atorvastatin in the management of CSDH, and reviewers performed a brief qualitative descriptive analysis of atorvastatin's efficacy in the management of CSDH.

RESULTS

Three eligible studies were included in this systematic review. Results indicated that atorvastatin accelerated hematoma absorption, decreased recurrence risk, and surgical requirement.

CONCLUSION

Limited evidence suggests that oral atorvastatin may be beneficial in the management of CSDH. Further high-quality studies focused on dosage, duration, hematoma size are needed to further elucidate the role of atorvastatin in the management of CSDH.

Association between antithrombotic drug use before chronic subdural haematoma and outcome after drainage: a systematic review and meta-analysis

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.

The management and outcome for patients with chronic subdural hematoma: a prospective, multicenter, observational cohort study in the United Kingdom

OBJECTIVE Symptomatic chronic subdural hematoma (CSDH) will become an increasingly common presentation in neurosurgical practice as the population ages, but quality evidence is still lacking to guide the optimal management for these patients. The British Neurosurgical Trainee Research Collaborative (BNTRC) was established by neurosurgical trainees in 2012 to improve research by combining the efforts of trainees in each of the United Kingdom (UK) and Ireland's neurosurgical units (NSUs). The authors present the first study by the BNTRC that describes current management and outcomes for patients with CSDH throughout the UK and Ireland. This provides a resource both for current clinical practice and future clinical research on CSDH. METHODS Data on management and outcomes for patients with CSDH referred to UK and Ireland NSUs were collected prospectively over an 8-month period and audited against criteria predefined from the literature: NSU mortality < 5%, NSU morbidity < 10%, symptomatic recurrence within 60 days requiring repeat surgery < 20%, and unfavorable functional status (modified Rankin Scale score of 4-6) at NSU discharge < 30%. RESULTS Data from 1205 patients in 26 NSUs were collected. Bur-hole craniostomy was the most common procedure (89%), and symptomatic recurrence requiring repeat surgery within 60 days was observed in 9% of patients. Criteria on mortality (2%), rate of recurrence (9%), and unfavorable functional outcome (22%) were met, but morbidity was greater than expected (14%). Multivariate analysis demonstrated that failure to insert a drain intraoperatively independently predicted recurrence and unfavorable functional outcome (p = 0.011 and p = 0.048, respectively). Increasing patient age (p < 0.00001), postoperative bed rest (p = 0.019), and use of a single bur hole (p = 0.020) independently predicted unfavorable functional outcomes, but prescription of high-flow oxygen or preoperative use of antiplatelet medications did not. CONCLUSIONS This is the largest prospective CSDH study and helps establish national standards. It has confirmed in a real-world setting the effectiveness of placing a subdural drain. This study identified a number of modifiable prognostic factors but questions the necessity of some common aspects of CSDH management, such as enforced postoperative bed rest. Future studies should seek to establish how practitioners can optimize perioperative care of patients with CSDH to reduce morbidity as well as minimize CSDH recurrence. The BNTRC is unique worldwide, conducting multicenter trainee-led research and audits. This study demonstrates that collaborative research networks are powerful tools to interrogate clinical research questions.

Clinical Course and Results of Surgery for Chronic Subdural Hematomas in Patients on Drugs Affecting Hemostasis

Objective

An apparent increase of use of drugs affecting hemostasis in our neurosurgical department since the 1990s has encouraged us to investigate whether these drugs influence the clinical course and results of surgery for chronic subdural hematoma (CSDH).

Methods

This retrospective analysis included 178 patients admitted for CSDH from 2007 to 2011 who were divided into two groups: on drugs affecting hemostasis (40; 22%) and no bleeding disorders (138; 78%). Medications in the first group included oral anticoagulants (33; 82.5%), antiplatelets (5; 12.5%) and low molecular weight heparins (2; 5%).

Results

The patients on drugs affecting hemostasis were older (74.3±7.4 vs. 68.4±14.8; p-value 0.01) and the group without bleeding disorders had more head trauma history (61% vs. 38%, p-value 0.01). The groups did not differ in bilateral hematoma rates (25% vs. 20%, p-value=NS). At diagnosis, mean hematoma thickness was lower in patients on drugs affecting hemostasis (18.7±7.4 mm vs. 21.9±7.9 mm, p-value<0.01). Average stay of hospital was 1 day longer in patients on drugs affecting hemostasis (11.7±4.1 vs.10.9±5.3, p-value=NS) and was related to the necessity of bleeding disorder reversal. Mean neurological status at presentation was similar between the groups (p-value=NS) as was the likelihood of hematoma recurrence (p-value=NS). Glasgow Outcome Scale results were comparable.

Conclusion

Patients on drugs affecting hemostasis are less often aware of a head trauma history, possibly suggesting a higher CSDH risk after minor trauma in this group. In these patients, smaller hematomas are symptomatic, probably due to faster hematoma formation. Drugs affecting hemostasis do not affect treatment results.

Burr-Hole Drainage for Chronic Subdural Hematoma Under Low-Dose Acetylsalicylic Acid: A Comparative Risk Analysis Study

BACKGROUND

Chronic subdural hematoma (cSDH) is one of the most common neurosurgical diseases typically affecting older people. Many of these patients have coronary artery disease and receive antiplatelet therapy, usually acetylsalicylic acid (ASA). Despite growing clinical relevance, there is still a lack of data focusing on the perioperative management of such patients.

OBJECTIVE

The aim of this study is to compare the perioperative and postoperative bleeding and cardiovascular complication rates of patients undergoing burr-hole drainage for cSDH with and without discontinuation of low-dose ASA.

METHODS

Of 963 consecutive patients undergoing burr-hole drainage for cSDH, 198 (20.5%) patients were receiving low-dose ASA treatment. In 26 patients (13.1%), ASA was not discontinued (ASA group; ASA discontinuation ≤7 days); in the remaining patients (n = 172; 86.9%), ASA was discontinued at least for 7 days (control group). The primary outcome measure was recurrent cSDH that required revision surgery owing to clinical symptoms, whereas secondary outcome measures were postoperative cardiovascular and thromboembolic events, other complications, operation and hospitalization time, morbidity, and mortality.

RESULTS

No statistically significant difference was observed between the 2 groups regarding recurrence of cSDH (P = 1). Cardiovascular event rates, surgical morbidity, and mortality did not significantly differ between patients with and without discontinuation of low-dose ASA.

CONCLUSION

Given the lack of guidelines regarding perioperative management with antiplatelet therapy, our findings elucidate one issue, showing comparable recurrence rates with and without discontinuation of low-dose ASA in patients undergoing burr-hole drainage for cSDH.