Elevated Serum Fibrinogen Degradation Products on Admission Is a Novel Predictive Factor for Recurrence of Chronic Subdural Hematoma

Predictive Value of Fibrin Fibrinogen Degradation Products-to-Potassium Ratio for Poor Functional Outcome in Patients with Aneurysmal Subarachnoid Hemorrhage: A Retrospective Case-Control Study

BACKGROUND

The relationship of fibrin(ogen) degradation products (FDPs) and potassium with the functional outcomes of patients with aneurysmal subarachnoid hemorrhage (aSAH) is still uncertain. This study aims to evaluate the predictive value of a novel combination biomarker, the FDP-to-potassium ratio (FPR), for poor functional outcomes in patients with aSAH.

METHODS

A total of 425 consecutive patients with aSAH at a single center were retrospectively enrolled in our study. An unfavorable outcome was defined as a modified Rankin Scale (mRS) score of 3-6 at 3 months after discharge. Univariate analysis and multivariable logistic regression were performed for baseline information and laboratory parameters recorded at admission. In addition, the receiver operating characteristic curve was plotted, and propensity score matching was performed based on the FPR.

RESULTS

On the basis of mRS grade, 301 patients were classified as having favorable outcomes, and 124 patients were assessed as having unfavorable outcomes. FPR levels were significantly correlated with mRS grade (r[Spearman] = 0.410; P < 0.001). Multivariate logistic regression analysis showed that age (odds ratio [OR] 1.043, 95% confidence interval [CI] 1.016-1.071; P = 0.002), white blood cell count (OR 1.150, 95% CI 1.044-1.267; P = 0.005), potassium (OR 0.526, 95% CI 0.291-0.949; P = 0.033), World Federation of Neurosurgical Societies grade (OR 1.276, 95% CI 1.055-1.544; P = 0.012), and FPR (OR 1.219, 95% CI 1.102-1.349; P < 0.001) at admission were independently associated with poor functional outcomes. The DeLong test showed that the area under the receiver operating characteristic curve of FPR was higher than that of age, white blood cell count, potassium, World Federation of Neurosurgical Societies grade, or FDP alone, indicating that FPR had better predictive potential than these other variables. After 1:1 propensity score matching (FPR ≥ 1.45 vs. FPR < 1.45), the rate of poor prognosis was still significantly increased in the high-FPR group (48/121 [39.7%] vs. 16/121 [13.2%], P < 0.001).

CONCLUSIONS

Fibrin(ogen) degradation product-to-potassium ratio is an independent predictor of poor outcomes for patients with aSAH and may be a promising tool for clinicians to evaluate patients' functional prognosis.

Biofluid Biomarkers in the Prognosis of Chronic Subdural Hematoma: A Systematic Scoping Review

The present systematic scoping review aimed at mapping and analyzing the available literature on biological fluid (biofluid) biomarkers showing promise in the prediction of chronic subdural hematoma (cSDH) recurrence and the prognosis of neurological/functional patient outcome. Twenty-three studies published between 2003 and 2023 investigating a diverse range of biomarkers in hematoma fluid and/or the circulation in 3749 patients were included. Immune cell populations and inflammatory/anti-inflammatory cytokines comprised the most studied category of biomarkers displaying significant findings. A notable time trend in biomarker studies was a recent shift in research focus towards the analysis of circulating biomarkers. Several biomarkers were indicated as independent predictors of cSDH recurrence and/or functional/neurological outcome, including circulating fibrinogen degradation products (FDP), brain natriuretic peptide (BNP-1) and high-density lipoprotein (HDL), as well as blood urea nitrogen (BUN) and the ratios of blood neutrophil to lymphocyte (NLR) or red blood cell distribution width to platelet count (RPR). While studies on cSDH prognostic biomarkers have gained, in recent years, momentum, additional multicenter prospective studies are warranted to confirm and extend their findings. The identification of prognostic biofluid biomarkers in cSDH is an active field of research that may provide future tools, guiding clinical decisions and allowing for the design of treatments based on risk stratification.

A novel rat model of chronic subdural hematoma: Induction of inflammation and angiogenesis in the subdural space mimicking human-like features of progressively expanding hematoma

Pathophysiological mechanisms of chronic subdural hematoma (CSDH) involve localized inflammation, angiogenesis, and dysregulated coagulation and fibrinolysis. The scarcity of reproducible and clinically relevant animal models of CSDH hinders further understanding the underlying pathophysiology and improving new treatment strategies. Here, we developed a novel rat model of CSDH using extracellular matrices (Matrigel) and brain microvascular endothelial cell line (bEnd.3 cells). One hundred-microliter of Matrigel-bEnd.3 cell (10⁶ cells per milliliter) mixtures were injected into the virtual subdural space of elderly male Sprague-Dawley rats. This approach for the first time led to a spontaneous and expanding subdural hematoma, encapsulated by internal and external neomembranes, formed as early as 3 d, reached its peak at 7 d, and lasted for more than 14 d, mimicking the progressive hemorrhage observed in patients with CSDH. The external neomembrane and hematoma fluid involved numerous inflammatory cells, fibroblasts, and highly fragile neovessels. Furthermore, a localized pathophysiological process was validated as evidenced by the increased expressions of inflammatory and angiogenic mediators in external neomembrane and hematoma fluid rather than in peripheral blood. Notably, the specific expression profiles of these mediators were closely associated with the dynamic changes in hematoma volume and neurological outcome. In summary, the CSDH model described here replicated the characteristics of human CSDH, and might serve as an ideal translational platform for preclinical studies. Meanwhile, the crucial roles of angiogenesis and inflammation in CSDH formation were reaffirmed.

A botanical medicine dragon's blood exhibited clinical antithrombosis efficacy similar to low molecular weight heparin

Deep vein thrombosis (DVT) is a common complication following traumatic fracture with a 0.5%-1% annual incidence. Low molecular weight heparin (LMWH) is the most commonly used anticoagulation drug for DVT prevention, but treatment with LMWH is invasive. Our aim is to compare the antithrombotic effect of dragon's blood, an oral botanical anticoagulant medicine approved by the Chinese FDA, with LMWH in patients undergoing hip fracture surgery and to explore the molecular mechanisms of anticoagulation treatment. Our study recruited patients and divided them into LMWH and dragon's blood treatment group. Coagulation index tests, Doppler ultrasound and mRNA sequencing were performed before and after anticoagulation therapy. There was no significant difference in postoperative DVT incidence between the two groups (23.1% versus 15.4%, P=0.694). D-dimer (D-D) and fibrinogen degradation product (FDP) showed significant reductions in both groups after anticoagulation treatments. We identified SLC4A1, PROS1, PRKAR2B and seven other genes as being differentially expressed during anticoagulation therapy in both groups. Genes correlated with coagulation indexes were also identified. Dragon's blood and LMWH showed similar effects on DVT and produced similar gene expression changes in patients undergoing hip fracture surgery, indicating that dragon's blood is a more convenient antithrombosis medicine (oral) than LMWH (hypodermic injection).

Gradation density hematoma is a predictor of chronic subdural hematoma recurrence associated with inflammation of the outer membrane

OBJECTIVES

Chronic subdural hematoma (CSDH) is a common form of intracranial hemorrhage with a high recurrence rate. This study aimed to determine the CSDH recurrence rate associated with preoperative computed tomography (CT) findings and the pathological examination of the dura and the outer membrane.

PATIENTS AND METHODS

We retrospectively reviewed the medical records of patients with CSDH who underwent surgery in our hospital between May 2010 and November 2019. CSDHs were classified into four groups according to the hematoma density on CT: low-density hematoma (LDH), gradation-density hematoma (GDH), iso-density-hematoma (IDH), and mixed-density hematoma (MDH). The postoperative recurrence rate was calculated for each group, and we examined whether the recurrence rate correlated with the CT findings. We also took samples of the dura to analyze inflammatory cell infiltration and the blood vessels.

RESULTS

A total of 388 patients were analyzed. The total recurrence rate was 13.7%. CT findings at admission showed LDH in 50, GDH in 136, IDH in 110, and MDH in 92 patients. The recurrence rate of GDH (23.5%, 32/136) was comparable to the rate of the other CSDH types (11.5%, 61/388). Univariate and multivariate analyses found GDH to be an independent risk factor for the recurrence of CSDH. GDH patients displayed much more angiogenesis and inflammatory cell infiltration in the outer membrane and the dura.

CONCLUSION

GDH is an independent predictor for CSDH recurrence. The presence of inflammation in GDH might be the primary cause of CSDH recurrence.

Risk factors of hospital mortality in chronic subdural hematoma: A retrospective analysis of 1117 patients, a single institute experience

Chronic subdural hematoma (CSDH) is not a benign disease in the elderly, and the mortality of CSDH is reported to be up to 32%. The study aimed to analyze hospital mortality and evaluate the risk factors in patients with CSDH. We retrospectively reviewed all patients with CSDH treated in the neurosurgery department of Renji hospital, School of Medicine, Shanghai Jiao Tong University from 10/2003 to 10/2018. Univariate and multivariate logistic regression analyses on the factors, including gender, age, Glasgow Coma Scale (GCS) on admission, main symptoms, history of head trauma, location of hematoma, density of subdural hematoma, laboratory tests on admission, et al, were performed. A total of 1117 patients with CSDH were included in the study, among which 20 patients died (mortality rate: 1.8%). Comparing the survival group and the death group, gender (p < 0.01), GCS on admission (p < 0.01), impaired consciousness as the presenting symptom (p = 0.041), history of head trauma (p = 0.02), location of hematoma (p = 0.03), platelet (p < 0.01), prealbumin (p = 0.046), albumin (p < 0.01), international normalized rate (INR) (p = 0.03), high sensitivity C-reactive protein (hsCRP) (p < 0.01), postoperative hyperthermia (p < 0.01) were shown to have significance. The logistic regression analysis revealed that GCS on admission (odds ratio [OR] 0.077, p < 0.01), bilateral CSDH (OR 0.100, p < 0.01 left CSDH as reference), prealbumin (OR 0.137, p = 0.02), INR (OR 12.959, p < 0.01) and hsCRP (OR 8.397, p < 0.01) were significantly associated with a higher mortality rate in CSDH. GCS on admission, bilateral CSDH, prealbumin, INR and hsCRP might be independent predictors of CSDH mortality.