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Angiogenetic Factors in Chronic Subdural Hematoma Development. Diagnostics (Basel) 2022; 12:diagnostics12112787. [PMID: 36428849 PMCID: PMC9689028 DOI: 10.3390/diagnostics12112787] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 10/15/2022] [Accepted: 11/04/2022] [Indexed: 11/16/2022] Open
Abstract
The levels of angiogenic factors were analyzed in eight patients who underwent the embolization of chronic subdural hematoma (CSDH) with non-adhesive liquid embolic agents. Four of these patients had previously undergone surgical treatment for hematoma removal and had recurrences of a similar volume, and four had an increase in hematoma volume due to rebleeding. The levels of vascular endothelial growth factor (VEGF), matrix metallopeptidase 9 (MMP 9), angiopoietin-2 (Ang2), transforming growth factor beta 1 (TGF-β1) and platelet-derived growth factor BB (PDGF-BB) in the arterial and venous blood were analyzed. The most significant results were obtained from the peripheral venous blood samples. The levels of VEGF in the samples of all the patients were close to normal or slightly decreased. There was an increase in the MMP9 levels (the factor that contributes to the disintegration of the vessel wall components) in all the patients. The Ang2 and especially the PDGF TGF-β1 (the factor that plays an important role in the growth of the vessel wall from the already existing blood vessel tissue) levels were distinctly low in most of the cases and slightly elevated only in a number of patients who had previously been operated on. The results obtained show that there is an imbalance in the angiogenesis factors in patients with rebleeding CSDH. At the same time, the factors determining the formation of the vessel wall were reduced, and the levels of factors contributing to the degradation of extracellular matrix components were significantly increased. Such factors could help us to anticipate the increased risk of hemorrhages. Highlights: The levels of VEGF, MMP 9, Ang2, TGF-β1 and PDGF-BB in the arterial and venous blood were analyzed. The most significant results were obtained from the peripheral venous blood samples. The results obtained show that there is an imbalance in the angiogenesis factors in patients with rebleeding CSDH. Such a profile of factors could help us to anticipate the increased risk of hemorrhages.
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Blaauw J, Meelis GA, Jacobs B, Gaag NA, Jellema K, Kho KH, Groen RJ, Naalt J, Lingsma HF, den Hertog HM. Presenting symptoms and functional outcome of chronic subdural hematoma patients. Acta Neurol Scand 2022; 145:38-46. [PMID: 34448196 DOI: 10.1111/ane.13518] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 07/23/2021] [Accepted: 08/04/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND Patients with chronic subdural hematoma (CSDH) can present with a variety of signs and symptoms. The relationship of these signs and symptoms with functional outcome is unknown. Knowledge of these associations might aid clinicians in the choice to initiate treatment and may allow them to better inform patients on expected outcomes. OBJECTIVE To investigate if presenting signs and symptoms influence functional outcome in patients with CSDH. METHODS We conducted a retrospective analysis of consecutive CSDH patients in three hospitals. Glasgow Outcome Scale Extended (GOS-E) scores were obtained from the first follow-up visit after treatment. An ordinal multivariable regression analysis was performed, to assess the relationship between the different signs and symptoms on the one hand and functional outcome on the other adjusted for potential confounders. RESULTS We included 1,307 patients, of whom 958 (73%) were male and mean age was 74 (SD ± 11) years. Cognitive complaints were associated with lower GOS-E scores at follow-up (aOR 0.7, 95% CI: 0.5 - 0.8) Headache and higher Glasgow Coma Scale (GCS) scores were associated with higher GOS-E scores. (aOR 1.9, 95% CI: 1.5-2.3 and aOR 1.3, 95% CI: 1.2-1.4). CONCLUSION Cognitive complaints are independently associated with worse functional outcome, whereas headache and higher GCS scores are associated with better outcome. The increased probability of unfavorable outcome in patients with CSDH who present with cognitive complaints favors a more prominent place of assessing cognitive status at diagnosis.
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Affiliation(s)
- Jurre Blaauw
- Department of Neurology University of GroningenUniversity Medical Center Groningen Groningen The Netherlands
- Center for Medical Decision Sciences Department of Public Health Erasmus Medical Center Rotterdam The Netherlands
| | | | - Bram Jacobs
- Department of Neurology University of GroningenUniversity Medical Center Groningen Groningen The Netherlands
| | - Niels A. Gaag
- University Neurosurgical Center Holland (UNCHLeiden University Medical CenterHaaglanden Medical Center & Haga teaching hospitalLeiden & The Hague The Hague The Netherlands
| | - Korné Jellema
- Department of Neurology Haaglanden Medical Centre The Hague The Netherlands
| | - Kuan H. Kho
- Department of Neurosurgery Medisch Spectrum Twente Enschede The Netherlands
| | - Rob J.M. Groen
- Department of Neurosurgery University Medical Center Groningen Groningen The Netherlands
| | - Joukje Naalt
- Department of Neurology University of GroningenUniversity Medical Center Groningen Groningen The Netherlands
| | - Hester F. Lingsma
- Center for Medical Decision Sciences Department of Public Health Erasmus Medical Center Rotterdam The Netherlands
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Predictors of Brain Natriuretic Peptide Serum Level Elevation in Patients with Symptomatic Chronic Subdural Hematoma: A Prospective Study. J Clin Med 2021; 10:jcm10081791. [PMID: 33924048 PMCID: PMC8073232 DOI: 10.3390/jcm10081791] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 04/14/2021] [Accepted: 04/15/2021] [Indexed: 11/20/2022] Open
Abstract
Background: Brain natriuretic peptide serum levels (BNP) on admission are frequently elevated in patients with symptomatic chronic subdural hematoma (cSDH) and predict unfavorable long-term functional outcomes. However, the reasons for these elevated levels remain unclear. Therefore, we aimed to identify the predictors of BNP elevation. Methods: Patients with unilateral symptomatic cSDH who were surgically treated in our department between November 2016 and May 2020 were enrolled. Patients’ symptoms and neurological deficits were prospectively assessed using a study questionnaire. On initial computer tomography, hematoma volumes and midline shift (MLS) values were measured to analyze the degree of brain compression. Results: In total, 100 patients were analyzed. Linear regression analysis showed that higher BNP levels were significantly associated with smaller hematoma volumes (p = 0.003) and littler MLS values (p = 0.022). Multivariate analysis revealed that presence of a neurological deficit (p = 0.041), a hematoma volume < 140 mL (p = 0.047), advanced age (p = 0.023), and head trauma within 24 h of admission (p = 0.001) were independent predictors of BNP elevation. Conclusion: In symptomatic cSDH, BNP elevation is related, among others, to the presence of neurological deficits and smaller hematoma volumes. Whether BNP elevation may coincide with the early stage of hematoma growth, i.e., immaturity of cSDH neomembrane, requires further investigations.
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Tiwari A, Dmytriw AA, Bo R, Farkas N, Ye P, Gordon DS, Arcot KM, Turkel-Parrella D, Farkas J. Recurrence and Coniglobus Volumetric Resolution of Subacute and Chronic Subdural Hematoma Post-Middle Meningeal Artery Embolization. Diagnostics (Basel) 2021; 11:diagnostics11020257. [PMID: 33562252 PMCID: PMC7915255 DOI: 10.3390/diagnostics11020257] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 02/01/2021] [Accepted: 02/04/2021] [Indexed: 12/21/2022] Open
Abstract
Objective: To study the efficacy of middle meningeal artery (MMA) embolization for the treatment of chronic subdural hematoma (SDH) and characterize its post-embolization volumetric resolution. Methods: Ten patients diagnosed with 13 cSDH underwent MMA embolization. SDH volumes were measured from time of initial discovery on imaging to pre-operative, post-operative, short-term and long-term follow-up. Time between procedure to obliteration was also measured. Volumetric analysis was done using the coniglobus formula, and recurrence rate as well as resolution timeline was defined using best-fit models. Results: Out of 10 patients, five were recurrent lesions, three were bilateral and seven unilateral cSDH. Average and median pre-operative volumes were 105.3 cc and 97.4 cc, respectively. Embolization on average was performed 21 days after discovery. Sixty percent of patients had concurrent antiplatelets or anticoagulation use. Forty percent underwent embolization treatment as the primary therapy. Recurrence was not seen in any patients treated with embolization. There were no peri- or post-operative complications. Five patients experienced complete or near-complete obliteration, while those with partial resolution showed a composite average of 75% volumetric reduction in 45 days. Post-embolization, the volumetric resolution followed an exponential decay curve over time and was independent of initial volume. Conclusion: MMA embolization contributed to a marked reduction in SDH volume post-operatively and can be used as a curative therapy for primary or recurrent chronic SDH.
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Affiliation(s)
- Ambooj Tiwari
- Interventional Neuro Associates, 43 Westminster Avenue, Bergenfield, NJ 06721, USA; (R.B.); (N.F.); (P.Y.); (K.M.A.); (D.T.-P.); (J.F.)
- Neuroradiology & Neurointervention Service, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02215, USA
- Departments of Neurology, Radiology & Neurosurgery, NYU School of Medicine & New York University Langone Health, Brooklyn, NY 11220, USA;
- Department of Vascular Neurology & Neurointerventional Surgery, NYU Grossman School of Medicine, 150 55th Street, Brooklyn, NY 11220, USA
- Correspondence: ; Tel.: +1-347-997-2202; Fax: +1-201-387-1036
| | - Adam A. Dmytriw
- Neuroradiology & Neurointervention Service, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02215, USA
| | - Ryan Bo
- Interventional Neuro Associates, 43 Westminster Avenue, Bergenfield, NJ 06721, USA; (R.B.); (N.F.); (P.Y.); (K.M.A.); (D.T.-P.); (J.F.)
- Departments of Neurology, Radiology & Neurosurgery, NYU School of Medicine & New York University Langone Health, Brooklyn, NY 11220, USA;
| | - Nathan Farkas
- Interventional Neuro Associates, 43 Westminster Avenue, Bergenfield, NJ 06721, USA; (R.B.); (N.F.); (P.Y.); (K.M.A.); (D.T.-P.); (J.F.)
- Department of Neurology, Washington University at St. Louis, 660 S Euclid Ave, St. Louis, MO 63110, USA
| | - Phillip Ye
- Interventional Neuro Associates, 43 Westminster Avenue, Bergenfield, NJ 06721, USA; (R.B.); (N.F.); (P.Y.); (K.M.A.); (D.T.-P.); (J.F.)
- Departments of Neurology, Radiology & Neurosurgery, NYU School of Medicine & New York University Langone Health, Brooklyn, NY 11220, USA;
| | - David S. Gordon
- Departments of Neurology, Radiology & Neurosurgery, NYU School of Medicine & New York University Langone Health, Brooklyn, NY 11220, USA;
| | - Karthikeyan M. Arcot
- Interventional Neuro Associates, 43 Westminster Avenue, Bergenfield, NJ 06721, USA; (R.B.); (N.F.); (P.Y.); (K.M.A.); (D.T.-P.); (J.F.)
- Departments of Neurology, Radiology & Neurosurgery, NYU School of Medicine & New York University Langone Health, Brooklyn, NY 11220, USA;
| | - David Turkel-Parrella
- Interventional Neuro Associates, 43 Westminster Avenue, Bergenfield, NJ 06721, USA; (R.B.); (N.F.); (P.Y.); (K.M.A.); (D.T.-P.); (J.F.)
- Departments of Neurology, Radiology & Neurosurgery, NYU School of Medicine & New York University Langone Health, Brooklyn, NY 11220, USA;
| | - Jeffrey Farkas
- Interventional Neuro Associates, 43 Westminster Avenue, Bergenfield, NJ 06721, USA; (R.B.); (N.F.); (P.Y.); (K.M.A.); (D.T.-P.); (J.F.)
- Departments of Neurology, Radiology & Neurosurgery, NYU School of Medicine & New York University Langone Health, Brooklyn, NY 11220, USA;
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Abstract
In chronic subdural hematoma (CSDH) patients, motor functions usually recover quickly after burr-hole surgery; however, in a rare case, the hemiparesis showed poor improvement after surgery. In that case, investigation of cerebral infarctions is important. Among the 284 CSDH patients with motor weakness, magnetic resonance image (MRI) and MR angiography (MRA) were acquired in 82 patients before surgery when the hemiparesis progressed rapidly. Small lacunar infarction was identified on the hematoma side in five cases; all were older than 80 years with hypertension, and diabetes mellitus had been diagnosed in two. In all the five patients (100%), MRA demonstrated a downward or upward shift of the M1 portion of the middle cerebral artery on the hematoma side, where the perforating arteries originate. Conversely, only 4 CSDH patients (5.2%) without lacunar infarction demonstrated M1 downward shift. The risk factors of lacunar infarction were high in the five detected cases; however, distortion, twisting, or elongation of the lenticulostriate arteries might be a cause of the lacunar infarctions, rather than the formation of lipohyalinosis or microatheroma in the arteries. Therefore, anti-platelet treatment might not be necessary for CSDH-inducing lacunar infarction. The lacunar infarctions caused by CSDH were small, the patients’ hemiparesis was mild, a prognosis of all the patients was good, and they recovered well from the motor weakness after physical rehabilitation. MR examinations before surgery are recommended for CSDH patients especially when a patient complains of sudden onset or rapid deterioration of motor weakness.
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Affiliation(s)
| | - Yusuke Tomita
- Department of Neurosurgery, Teikyo University Mizonokuchi Hospital
| | - Yoshinori Takaya
- Department of Neurosurgery, Teikyo University Mizonokuchi Hospital
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Motiei-Langroudi R, Alterman RL, Stippler M, Phan K, Alturki AY, Papavassiliou E, Kasper EM, Arle J, Ogilvy CS, Thomas AJ. Factors influencing the presence of hemiparesis in chronic subdural hematoma. J Neurosurg 2019; 131:1926-1930. [PMID: 30641839 DOI: 10.3171/2018.8.jns18579] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Accepted: 08/28/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Chronic subdural hematoma (CSDH) has a variety of clinical presentations, including hemiparesis. Hemiparesis is of the utmost importance because it is one of the major indications for surgical intervention and influences outcome. In the current study, the authors intended to identify factors influencing the presence of hemiparesis in CSDH patients and to determine the threshold value of hematoma thickness and midline shift for development of hemiparesis. METHODS The authors retrospectively reviewed 325 patients (266 with unilateral and 59 with bilateral hematomas) with CSDH who underwent surgical evacuation, regardless of presence or absence of hemiparesis. RESULTS In univariate analysis, hematoma loculation, age, hematoma maximal thickness, and midline shift were significantly associated with hemiparesis. Moreover, patients with unilateral hematomas had a higher rate of hemiparesis than patients with bilateral hematomas. Sex, trauma history, anticoagulant and antiplatelet drug use, presence of comorbidities, Glasgow Coma Scale score, hematoma density characteristics on CT scan, and hematoma signal intensity on T1- and T2-weighted MRI were not associated with hemiparesis. In multivariate analysis, the presence of loculation and hematoma laterality (unilateral vs bilateral) influenced hemiparesis. For unilateral hematomas, maximal hematoma thickness of 19.8 mm and midline shift of 6.4 mm were associated with a 50% probability of hemiparesis. For bilateral hematomas, 29.0 mm of maximal hematoma thickness and 6.8 mm of shift were associated with a 50% probability of hemiparesis. CONCLUSIONS Presence of loculations, unilateral hematomas, older patient age, hematoma maximal thickness, and midline shift were associated with a higher rate of hemiparesis in CSDH patients. Moreover, 19.8 mm of hematoma thickness and 6.4 mm of midline shift were associated with a 50% probability of hemiparesis in patients with unilateral hematomas.
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Affiliation(s)
- Rouzbeh Motiei-Langroudi
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- 2Department of Neurological Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Ron L Alterman
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Martina Stippler
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Kevin Phan
- 3University of Sydney Westmead Clinical School, Westmead, New South Wales, Australia
| | - Abdulrahman Y Alturki
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- 4Department of Neurosurgery, The National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia; and
| | - Efstathios Papavassiliou
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ekkehard M Kasper
- 5Division of Neurosurgery, Hamilton General Hospital, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Jeffrey Arle
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Christopher S Ogilvy
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ajith J Thomas
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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