Chronic subdural hematoma associated with dural metastasis leads to early recurrence and death: A single-institute, retrospective cohort study

Subdural Hematoma due to Dural Metastasis: A Systematic Review on Frequency, Clinical Characteristics, and Neurosurgical Management

BACKGROUND

 Subdural hematoma (SDH) occasionally accompanies dural metastasis and is associated with high recurrence rate, significantly impacting patient morbidity and mortality. This systematic review aims to evaluate the characteristics, management options, and outcomes of patients with SDH associated with dural metastasis.

METHODS

 A comprehensive search of the PubMed and Cochrane databases was conducted for English-language studies published from inception to March 20, 2023, adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The authors reviewed cases of histopathologically confirmed SDH with non-central nervous system (non-CNS) tumor metastasis, focusing on therapeutic management of SDH. Statistical analysis was performed using SPSS software, with a significance level set at 0.05.

RESULTS

 This review included 32 studies comprising 37 patients with 43 SDH cases associated with dural metastasis. Chronic SDH was the most frequently observed presentation (n = 28, 65.12%). The systemic malignancies most commonly associated with SDH due to dural metastasis were prostate carcinoma (n = 9, 24.32%) and gastric carcinoma (n = 5, 13.51%). A statistically significant association was found between metastatic melanoma and subacute SDH (p = 0.010). The majority of patients were treated with burr holes (n = 15, 40.54%) or craniotomies (n = 14, 37.84%), with no statistically significant difference in mortality rates between the two techniques (p = 0.390). Adjuvant therapy was administered to a limited number of patients (n = 5, 13.51%), including chemotherapy (n = 2, 5.41%), whole brain radiotherapy (n = 1, 2.70%), a combination of chemotherapy and whole brain radiotherapy (n = 1, 2.70%), and transcatheter arterial chemoembolization (n = 1, 2.70%). The overall recurrence rate was 45.95% (n = 17), with burr holes being the most common management approach (n = 4, 10.81%). Within a median of 8 days, 67.57% (n = 25) of patients succumbed, primarily due to rebleeding (n = 3, 8.11%), disseminated intravascular coagulation (n = 3, 8.11%), and pneumonia (n = 3, 8.11%).

CONCLUSION

 This review highlights the need for improving existing neurosurgical options and exploring novel treatment methods. It also emphasizes the importance of dural biopsy in patients with suspected metastasis to rule out a neoplastic etiology.

Vascular complications in patients with brain tumors

PURPOSE OF REVIEW

Venous thromboembolism (VTE) and other vascular events are common in patients with brain tumors, but their optimal management is not firmly established, in large part due to the competing risk of intracranial hemorrhage (ICH) in this population.

RECENT FINDINGS

There is conflicting evidence on whether therapeutic anticoagulation increases the risk of ICH in patients with brain tumors, with several metanalysis and retrospective cohort studies showing an increased risk and others showing no differences. Current guidelines recommend anticoagulating brain tumors patients with VTE with either low-molecular weight heparin (LMWH) or direct oral anticoagulants (DOACs), and several retrospective studies have shown the risk of ICH with DOACs is similar or smaller than with LMWH.

SUMMARY

An increased risk of VTE exists in a variety of brain tumor types. Most patients with brain tumors and VTE should receive therapeutic anticoagulation, and recent retrospective evidence supports the use of both LMWH and DOACs as effective and relatively safe in this setting. Patients with brain tumors are also at increased risk of other vascular tumor- or treatment-related complications whose optimal management is unclear.

Case report: Rapid recurrence of a chronic subdural haematoma associated with prostate cancer metastasis to a haematoma capsule

Background

Chronic subdural haematoma (CSDH) has various causes, including trauma, coagulopathies, and intracranial hypotension. However, CSDH associated with extracranial malignancy is rare. Here, we report an extremely rare case of CSDH due to prostate cancer metastasis to a haematoma capsule.

Case Description

A 79-year-old man with a history of prostate cancer had a progressive decline in consciousness during hospitalization for cancer treatment. CSDH was diagnosed from computed tomography (CT) imaging. We urgently performed burr hole drainage, and the patient’s symptoms improved rapidly after surgery. After removing the drainage tube, the patient’s symptoms worsened again, and the repeat head CT suggested recurrence of CSDH. In a second operation, most of the haematoma capsule was excised under craniotomy, and the thickened haematoma capsule was sent for routine pathologic examination. Pathological findings confirmed the metastasis of prostate cancer to the haematoma capsule, which we believed to be related to a rapid recurrence of CSDH. After the second operation, the disease course progressed without CSDH recurrence.

Conclusions

For patients with malignant tumours diagnosed with CSDH, the possibility of metastasis to a haematoma capsule needs to be considered. Burr holes and drainage can easily lead to a rapid relapse. Excision of the haematoma capsule is the key to successful treatment.