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Albalkhi I, Alaswad M, Saleh T, Senjab A, Helal B, Khan JA. Adjuvant Tranexamic Acid for Reducing Postoperative Recurrence of Chronic Subdural Hematoma in the Elderly: A Systematic Review and Meta-Analysis. World Neurosurg 2024; 182:e829-e836. [PMID: 38101544 DOI: 10.1016/j.wneu.2023.12.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 12/09/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND Chronic subdural hematoma (CSDH) is a frequently encountered neurosurgical disease among the elderly. The mainstay treatment involves surgical evacuation, but recurrence rates of approximately 13% pose complications. Adjuvant treatments, including tranexamic acid (TXA), have been explored, yet consensus on their efficacy and safety in elderly patients remains uncertain. The study aims to examine the role of TXA as adjunctive therapy in reducing CSDH recurrence and explore any potential association between TXA use and thrombotic events in this patient population. METHODS The systematic review and meta-analysis adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and Cochrane Handbook standards, searching databases up to July 2023 for randomized controlled trials and propensity-matched cohorts evaluating adjuvant TXA. The primary outcome was CSDH recurrence, and the secondary outcome was thrombosis risk, measured as relative risks. RESULTS A total of 6 studies were included, comprising 1403 patients with CSDH who underwent surgical treatment. Four studies were randomized controlled trials, while the other 2 were propensity-matched cohorts. The overall pooled relative risk for CSDH recurrence in the TXA group compared to the control group was 0.41 (95% confidence interval [0.29-0.59], P < 0.01), indicating a significant reduction in recurrence with TXA treatment. CONCLUSIONS In conclusion, our study indicates that adjuvant TXA may help reduce CSDH recurrence in elderly patients undergoing surgical treatment. However, the study has limitations and there is a need for further research to validate these findings.
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Affiliation(s)
- Ibrahem Albalkhi
- Department of Neuroscience, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia; Department of Neuroradiology, Great Ormond Street Hospital NHS Foundation Trust, London, United Kingdom.
| | - Marwan Alaswad
- Department of Neuroscience, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Tariq Saleh
- Department of Neuroscience, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Abdulrahaman Senjab
- Department of Neuroscience, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Baraa Helal
- Department of Neuroscience, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Jibran Ahmad Khan
- Department of Neuroscience, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
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Jeon GJ, Rim HT, Lee HS, Oh JK, Chang IB, Song JH, Kim JH. Factors for predicting recurrence after burr hole drainage for chronic subdural hematoma: a retrospective study. Neurosurg Rev 2023; 46:306. [PMID: 37982885 DOI: 10.1007/s10143-023-02222-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 11/03/2023] [Accepted: 11/14/2023] [Indexed: 11/21/2023]
Abstract
Chronic subdural hematoma (SDH) is a common disease in the neurosurgical field, and hematoma drainage through burr hole trephination has been widely considered the optimal treatment for SDH. Despite numerous investigations aimed at predicting recurrence rates and associated factors, studies have demonstrated inconsistent results. In this study, we aimed to comprehensively determine the predictive factors of chronic SDH recurrence in surgically treated patients. We retrospectively evaluated 578 consecutive patients who underwent single burr hole surgery for chronic SDH at our institute between January 2008 and December 2021. Various clinical and radiological factors in patients with and without recurrence were compared using univariate and multivariate logistic regression analyses. A total of 438 patients (531 hemispheres) were analyzed. Fifty-four (10.17%) of the 531 hemispheres had recurrence of chronic SDH within 6 months. Male sex (adjusted odds ratio (aOR) = 3.48; 95% confidence interval (CI), 1.42-8.49), bilateral hematomas (aOR = 2.14; 95% CI, 1.05-4.35), laminar hematoma type (aOR = 2.87; 95% CI, 1.23-6.71), > 30-cm3 volume of postoperative residual hematoma (aOR = 2.99; 95% CI, 1.01-8.83), and preoperative blood glucose level of ≥ 150 mg/dL (aOR = 2.11; 95% CI, 1.10-4.05) were identified as independent factors associated with recurrence in multivariate logistic regression analysis. The present study revealed that male patients and those who had bilateral hematomas, laminar hematoma type, a large volume of hematoma after surgery, and a high preoperative blood glucose level had a higher probability of experiencing recurrent chronic SDH. We recommend close monitoring of patients 6 months postoperatively to detect subsequent chronic SDH recurrence.
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Affiliation(s)
- Gi Jeong Jeon
- Department of Neurosurgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, 22, Gwanpyeong-Ro 170Beon-Gil, Dongan-Gu, Anyang-Si, Gyeonggi-Do, 14068, Republic of Korea
| | - Hyun Taek Rim
- Department of Neurosurgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, 22, Gwanpyeong-Ro 170Beon-Gil, Dongan-Gu, Anyang-Si, Gyeonggi-Do, 14068, Republic of Korea
| | - Heui Seung Lee
- Department of Neurosurgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, 22, Gwanpyeong-Ro 170Beon-Gil, Dongan-Gu, Anyang-Si, Gyeonggi-Do, 14068, Republic of Korea
| | - Jae Keun Oh
- Department of Neurosurgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, 22, Gwanpyeong-Ro 170Beon-Gil, Dongan-Gu, Anyang-Si, Gyeonggi-Do, 14068, Republic of Korea
| | - In Bok Chang
- Department of Neurosurgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, 22, Gwanpyeong-Ro 170Beon-Gil, Dongan-Gu, Anyang-Si, Gyeonggi-Do, 14068, Republic of Korea
| | - Joon Ho Song
- Department of Neurosurgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, 22, Gwanpyeong-Ro 170Beon-Gil, Dongan-Gu, Anyang-Si, Gyeonggi-Do, 14068, Republic of Korea
| | - Ji Hee Kim
- Department of Neurosurgery, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, 22, Gwanpyeong-Ro 170Beon-Gil, Dongan-Gu, Anyang-Si, Gyeonggi-Do, 14068, Republic of Korea.
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Shimohigoshi W, Takase H, Haze T, Kobayashi Y, Manaka H, Kawasaki T, Sakata K, Yamamoto T. Renin-angiotensin-aldosterone system inhibitors as a risk factor for chronic subdural hematoma recurrence: A matter of debate. J Stroke Cerebrovasc Dis 2023; 32:107291. [PMID: 37579641 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 06/28/2023] [Accepted: 08/01/2023] [Indexed: 08/16/2023] Open
Abstract
OBJECTIVES Chronic subdural hematoma (cSDH) is a common central nervous system condition. Recent reports indicate that cSDH affects long-term prognosis; however, its definitive risk factors remain unknown. An antihypertensive drug, renin-angiotensin-aldosterone system inhibitors (RAASi), can affect vascular permeability and cell proliferation processes, which may suppress the recurrence of cSDH. However, several studies have reported negative results to this effect. Therefore, we aimed to evaluate antihypertensive drugs, including RAASi, as risk factors for recurrent cSDH. MATERIALS AND METHODS A total of 203 consecutive cases of surgically treated cSDH were retrospectively reviewed. Clinical and radiological parameters were compared between the groups with and without cSDH recurrence to identify risk factors. RESULTS Of the included cases, 68 (33.5%) used RAASi and 37 (18.2%) developed recurrence within 60 days of surgery. In the multiple logistic regression analysis adjusted by composite risk score, the odds ratios (95% confidence interval) of RAASi, calcium channel blockers, diuretics, β and α blockers, for the recurrent risk of cSDH after surgery were 2.49 (1.16, 5.42), 1.79 (0.84, 3.82), 1.83 (0.62, 4.87), 0.90 (0.28, 2.44), and 0.96 (0.21, 3.20), respectively. The Cox proportional hazard model also demonstrated that RAASi-use was an independent risk factor for cSDH recurrence. CONCLUSIONS Present series suggests RAASi-use as a risk factor for cSDH recurrence, although the role of RAASi-use in cSDH remains debatable. Further studies for deeper understanding of the microenvironment of hematoma and the surroundings are preferable. (235 words).
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Affiliation(s)
- Wataru Shimohigoshi
- Department of Neurosurgery, Yokohama City University Medical Center, Yokohama, Japan
| | - Hajime Takase
- Center for Novel and Exploratory Clinical Trials (Y-NEXT), Yokohama City University Hospital, Yokohama, Japan; Department of Neurosurgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan.
| | - Tatsuya Haze
- Center for Novel and Exploratory Clinical Trials (Y-NEXT), Yokohama City University Hospital, Yokohama, Japan; Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan.; Department of Nephrology and Hypertension, Yokohama City University Medical Center, Yokohama, Japan
| | - Yusuke Kobayashi
- Center for Novel and Exploratory Clinical Trials (Y-NEXT), Yokohama City University Hospital, Yokohama, Japan; Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Hiroshi Manaka
- Department of Neurosurgery, Yokohama City University Medical Center, Yokohama, Japan
| | - Takashi Kawasaki
- Department of Neurosurgery, Yokohama City University Medical Center, Yokohama, Japan
| | - Katsumi Sakata
- Department of Neurosurgery, Yokohama City University Medical Center, Yokohama, Japan
| | - Tetsuya Yamamoto
- Department of Neurosurgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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Wu L, Guo X, Ou Y, Yu X, Zhu B, Yang C, Liu W. Efficacy analysis of neuroendoscopy-assisted burr-hole evacuation for chronic subdural hematoma: a systematic review and meta-analysis. Neurosurg Rev 2023; 46:98. [PMID: 37115314 DOI: 10.1007/s10143-023-02007-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 03/13/2023] [Accepted: 04/23/2023] [Indexed: 04/29/2023]
Abstract
The purpose of this study was to compare neuroendoscopy-assisted burr-hole evacuation with conventional burr-hole evacuation in the treatment of chronic subdural hematoma (CSDH), and to evaluate the curative effect of neuroendoscopy. This study follows PRISMA guidelines and uses the keywords "chronic subdural hematoma," "neuroendoscopies," "neuroendoscopy," "endoscopy," "endoscopic neurosurgery," and "neuroendoscopic surgery" to conduct an electronic search of online databases, including PubMed, Embase, Web of Science, and Cochrane Library. There were no restrictions on language or publication year. This meta-analysis involved 948 patients in six studies. The results showed that the recurrence rate in the neuroendoscopy group was significantly lower than that in the conventional burr-hole group (3.1% vs. 13.8%, P<0.001). Compared with the control group, the neuroendoscopy group had a longer operation time (P<0.001) and a shorter postoperative drainage time (P<0.001). In addition, there was no significant difference in hospital stay (P=0.14), mortality (P=0.39), postoperative morbidity (P=0.12), or 6-month neurological outcomes (P=0.32) between the two groups. It should be noted that the comparison of neurological outcomes was based on 269 patients (6/106 vs. 14/163). Compared with conventional burr-hole evacuation, neuroendoscopy-assisted burr-hole evacuation reduces the recurrence rate of CSDH and shortens the postoperative drainage time. However, the neuroendoscopy group did not have lower mortality or morbidity or better functional outcomes. In the future, randomized controlled trials are needed to further evaluate the efficacy and safety of neuroendoscopic surgery.
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Affiliation(s)
- Liang Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xufei Guo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yunwei Ou
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, Beihang University, Beijing, China
| | - Xiaofan Yu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Bingcheng Zhu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Cheng Yang
- The Third Clinical Medical College, Ningxia Medical University, Yinchuan, China
| | - Weiming Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
- China National Clinical Research Center for Neurological Diseases, Beijing, China.
- Neurological Center, People's Hospital of Ningxia Hui Autonomous Region (The Third Clinical Medical College, Ningxia Medical University), Yinchuan, China.
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Wu L, Ou Y, Zhu B, Guo X, Yu X, Xu L, Li J, Feng E, Li H, Wang X, Chen H, Sun Z, Liu Z, Yang D, Zhang H, Liu Z, Tang J, Zhao S, Zhang G, Yao J, Ma D, Sun Z, Zhou H, Liu B, Liu W. Exhaustive drainage versus fixed-time drainage for chronic subdural hematoma after one-burr hole craniostomy (ECHO): study protocol for a multicenter randomized controlled trial. Trials 2023; 24:207. [PMID: 36941714 PMCID: PMC10029260 DOI: 10.1186/s13063-023-07250-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 03/13/2023] [Indexed: 03/22/2023] Open
Abstract
BACKGROUND Chronic subdural hematomas (CSDHs) are one of the most common neurosurgical conditions. The standard surgical technique includes burr-hole craniostomy, followed by intraoperative irrigation and placement of subdural closed-system drainage. The drainage is generally removed after 48 h, which can be described as fixed-time drainage strategy. According to literature, the recurrence rate is 5-33% with this strategy. In our retrospective study, postoperative hematoma volume was found to significantly increase the risk of recurrence. Based on these results, an exhaustive drainage strategy is conducted to minimize postoperative hematoma volume and achieve a low recurrence rate and good outcomes. METHODS This is a prospective, multicenter, open-label, blinded endpoint randomized controlled trial designed to include 304 participants over the age of 18-90 years presenting with a symptomatic CSDH verified on cranial computed tomography or magnetic resonance imaging. Participants will be randomly allocated to perform exhaustive drainage (treatment group) or fixed-time drainage (control group) after a one-burr hole craniostomy. The primary endpoint will be recurrence indicating a reoperation within 6 months. DISCUSSION This study will validate the effect and safety of exhaustive drainage after one-burr hole craniostomy in reducing recurrence rates and provide critical information to improve CSDH surgical management. TRIAL REGISTRATION Clinicaltrials.gov, NCT04573387. Registered on October 5, 2020.
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Affiliation(s)
- Liang Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yunwei Ou
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Bingcheng Zhu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xufei Guo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xiaofan Yu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Long Xu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jinping Li
- Department of Neurosurgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Enshan Feng
- Department of Neurosurgery, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Huaqing Li
- Department of Neurosurgery, Xinxing County People's Hospital, Yunfu, Guangdong, China
| | - Xiaodong Wang
- Department of Neurosurgery, Puning People's Hospital, Puning, Guangdong, China
| | - Huaqun Chen
- Department of Neurosurgery, Yancheng Third People's Hospital, Yancheng, Jiangsu, China
| | - Zhaosheng Sun
- Department of Neurosurgery, Hengshui People's Hospital, Hengshui, Hebei, China
| | - Zaofu Liu
- Department of Neurosurgery, Wei County Hospital of Traditional Chinese Medicine, Handan, Hebei, China
| | - Dawei Yang
- Department of Neurosurgery, First Hospital of Qinhuangdao, Qinhuangdao, Hebei, China
| | - Hongbing Zhang
- Department of Neurosurgery, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Zhigang Liu
- Department of Neurosurgery, Xiahuayuan District Hospital, Zhangjiakou, Hebei, China
| | - Jie Tang
- Department of Neurosurgery, Beijing Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Shangfeng Zhao
- Department of Neurosurgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Guobin Zhang
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Jiemin Yao
- Department of Neurosurgery, The Second Nanning People's Hospital, Nanning, Guangxi, China
| | - Dongming Ma
- Department of Neurosurgery, People's Hospital of Ningxia Hui Autonomous Region, Yinchuan, Ningxia, China
| | - Zelin Sun
- Department of Neurosurgery, North China University of Science and Technology Affiliated Hospital, Tangshan, Hebei, China
| | - Hui Zhou
- Department of Neurosurgery, First People's Hospital of Lianyungang, Lianyungang, Jiangsu, China
| | - Baiyun Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Weiming Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
- China National Clinical Research Center for Neurological Diseases, Beijing, China.
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Development and validation of a recurrent prediction model for patients with unilateral chronic subdural hematoma without hematoma volumetric analysis. Clin Neurol Neurosurg 2023; 227:107678. [PMID: 36933403 DOI: 10.1016/j.clineuro.2023.107678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 03/11/2023] [Accepted: 03/14/2023] [Indexed: 03/18/2023]
Abstract
OBJECTIVE Approximately 10 % of patients with chronic subdural hematoma (CSDH) undergo reoperation after initial surgery. This study aimed to develop a predictive model for the recurrence of unilateral CSDH at initial surgery without hematoma volumetric analysis. METHODS This single-center retrospective cohort study evaluated pre- and postoperative computed tomography (CT) images of patients with unilateral CSDH. The pre- and postoperative midline shift (MLS), residual hematoma thickness, and subdural cavity thickness (SCT) were measured. CT images were classified based on the internal architecture of the hematoma (homogenous, laminar, trabecular, separated, and gradation subtypes). RESULTS Total 231 patients with unilateral CSDH underwent burr hole craniostomy. After receiver operating characteristic analysis, preoperative MLS and postoperative SCT showed better areas under the curve (AUCs) (0.684 and 0.756, respectively). According to the CT classification of preoperative hematomas, the recurrence rate was significantly higher in the separated/gradation group (18/97, 18.6 %) than in the homogenous/laminar/trabecular group (10/134, 7.5 %). Four-point score was derived from the multivariate model using the preoperative MLS, postoperative SCT, and CT classification. The AUC of this model was 0.796, and the recurrence rates at 0-4 points were 1.7 %, 3.2 %, 13.3 %, 25.0 %, and 35.7 %, respectively. CONCLUSION Pre- and postoperative CT findings without hematoma volumetric analysis may predict CSDH recurrence.
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Ku JC, Dmytriw AA, Essibayi MA, Banihashemi MA, Vranic JE, Ghozy S, Altschul D, Regenhardt RW, Stapleton CJ, Yang VXD, Patel AB. Embolic Agent Choice in Middle Meningeal Artery Embolization as Primary or Adjunct Treatment for Chronic Subdural Hematoma: A Systematic Review and Meta-analysis. AJNR Am J Neuroradiol 2023; 44:297-302. [PMID: 36797028 PMCID: PMC10187811 DOI: 10.3174/ajnr.a7796] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 01/24/2023] [Indexed: 02/18/2023]
Abstract
BACKGROUND Middle meningeal artery embolization is an emerging treatment option for chronic subdural hematomas. PURPOSE Our aim was to assess outcomes following middle meningeal artery embolization by different techniques, including in comparison with traditional surgical methods. DATA SOURCES We searched the literature databases from inception to March 2022. DATA SELECTION We selected studies reporting outcomes after middle meningeal artery embolization as a primary or adjunctive treatment for chronic subdural hematoma. DATA ANALYSIS We analyzed the risk of recurrence of chronic subdural hematoma, reoperation for recurrence or residual hematoma, complications, and radiologic and clinical outcomes using random effects modeling. Additional analyses were performed on the basis of whether middle meningeal artery embolization was used as the primary or adjunct treatment and by embolic agent type. DATA SYNTHESIS Twenty-two studies were included with 382 patients with middle meningeal artery embolization and 1373 surgical patients. The rate of subdural hematoma recurrence was 4.1%. Fifty (4.2%) patients underwent a reoperation for a recurrent or residual subdural hematoma. Thirty-six (2.6%) experienced postoperative complications. The rates of good radiologic and clinical outcomes were 83.1% and 73.3%, respectively. Middle meningeal artery embolization was significantly associated with decreased odds of subdural hematoma reoperation (OR = 0.48; 95% CI, 23.4-99.1; P = .047) compared with surgery. The lowest rates of subdural hematoma radiologic recurrence, reoperation, and complications were observed among patients receiving embolization with Onyx, whereas good overall clinical outcome occurred most commonly with combined polyvinyl alcohol and coils. LIMITATIONS A limitation was the retrospective design of studies included. CONCLUSIONS Middle meningeal artery embolization is safe and effective, either as a primary or adjunctive treatment. Treatment using Onyx seems to yield lower rates of recurrence, rescue operation, and complications whereas particles and coils produce good overall clinical outcomes.
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Affiliation(s)
- J C Ku
- From the Division of Neurosurgery (J.C.K.)
| | - A A Dmytriw
- Neuroendovascular Program (A.A.D., J.E.V., R.W.R., C.J.S., A.B.P.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- Neurointerventional Program (A.A.D., V.X.D.Y.), Department of Clinical Neurological Sciences & Medical Imaging, Schulich School of Medicine, Western University, London, Ontario, Canada
| | - M A Essibayi
- Departments of Radiology (M.A.E., S.G.), Mayo Clinic, Rochester, Minnesota
- Department of Neurosurgery (M.A.E., D.A.), Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York
| | - M A Banihashemi
- Department of Surgery and Institute of Medical Science (M.A.B.), University of Toronto, Toronto, Ontario, Canada
| | - J E Vranic
- Neuroendovascular Program (A.A.D., J.E.V., R.W.R., C.J.S., A.B.P.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - S Ghozy
- Departments of Radiology (M.A.E., S.G.), Mayo Clinic, Rochester, Minnesota
- Nuffield Department of Primary Care Health Sciences and Department for Continuing Education (EBHC program) (S.G.), Oxford University, Oxford, UK
| | - D Altschul
- Department of Neurosurgery (M.A.E., D.A.), Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York
| | - R W Regenhardt
- Neuroendovascular Program (A.A.D., J.E.V., R.W.R., C.J.S., A.B.P.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - C J Stapleton
- Neuroendovascular Program (A.A.D., J.E.V., R.W.R., C.J.S., A.B.P.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - V X D Yang
- Neurointerventional Program (A.A.D., V.X.D.Y.), Department of Clinical Neurological Sciences & Medical Imaging, Schulich School of Medicine, Western University, London, Ontario, Canada
| | - A B Patel
- Neuroendovascular Program (A.A.D., J.E.V., R.W.R., C.J.S., A.B.P.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Zeng L, Yu J, Chen R, Yang H, Li H, Zeng L, Wang J, Xu W, Hu S, Chen K. Modified Valsalva maneuver after burr-hole drainage of chronic subdural hematomas: A single-center cohort study. Front Neurol 2023; 13:1069708. [PMID: 36793801 PMCID: PMC9924088 DOI: 10.3389/fneur.2022.1069708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 12/28/2022] [Indexed: 01/31/2023] Open
Abstract
Background Previous studies on the management of chronic subdural hematoma (cSDH) mainly focused on the risk of postoperative recurrence and measures to prevent it. In this study, we propose the use of a non-invasive postoperative treatment method, the modified Valsalva maneuver (MVM), as a means of reducing the recurrence of cSDH. This study aims to clarify the effects of MVM on functional outcomes and recurrence rates. Methods A prospective study was conducted at the Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology from November 2016 to December 2020. The study included 285 adult patients who underwent burr-hole drainage for the treatment of cSDH and received subdural drains. These patients were divided into two groups: the MVM group (n = 117) and the control group (n = 98). In the MVM group, patients received treatment with a customized MVM device for at least 10 times per hour, 12 h per day. The study's primary endpoint was the recurrence rate of SDH, while functional outcomes and morbidity 3 months after surgery were the secondary outcomes. Results In the current study, 9 out of 117 patients (7.7%) in the MVM group experienced a recurrence of SDH, while 19 out of 98 patients (19.4%, p < 0.05) in the HC group experienced a recurrence of SDH. Additionally, the infection rate of diseases such as pneumonia (1.7%) was significantly lower in the MVM group compared to the HC group (9.2%, p < 0.001, odds ratio (OR = 0.1). After 3 months of the surgery, 109 out of 117 patients (93.2%) in the MVM group achieved a favorable prognosis, compared to 80 out of 98 patients (81.6%) in the HC group (p = 0.008, with an OR of 2.9). Additionally, infection rate (with an OR of 0.2) and age (with an OR of 0.9) are independent predictors of a favorable prognosis at the follow-up stage. Conclusions The use of MVM in the postoperative management of cSDHs has been shown to be safe and effective, resulting in reduced rates of cSDH recurrence and infection following burr-hole drainage. These findings suggest that MVM treatment may lead to a more favorable prognosis at the follow-up stage.
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Fuentes AM, Khalid SI, Mehta AI. Predictors of Subsequent Intervention After Middle Meningeal Artery Embolization for Treatment of Subdural Hematoma: A Nationwide Analysis. Neurosurgery 2023; 92:144-149. [PMID: 36129273 DOI: 10.1227/neu.0000000000002151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 07/16/2022] [Indexed: 12/25/2022] Open
Abstract
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.
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Affiliation(s)
- Angelica M Fuentes
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
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10
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Jarrar S, Al Barbarawi MM, Daoud SS, Samara QA, Qarqash AA, Alawneh RJ, Abu-amoud NA, Ababneh OE, Jbarah OF. Management of chronic subdural hematoma: A study from Jordan. J Taibah Univ Med Sci 2022; 17:1021-1030. [PMID: 36212589 PMCID: PMC9519793 DOI: 10.1016/j.jtumed.2022.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 06/08/2022] [Accepted: 06/23/2022] [Indexed: 11/17/2022] Open
Abstract
Objectives Chronic subdural hematoma (CSDH) is a common condition encountered in neurosurgical practice. Few studies have reported the characteristics of CSDH patients in the Middle Eastern population. We describe the clinical presentation, surgical management, radiological findings, and post-operative outcomes in our hospital. Methods We performed a retrospective cohort study in King Abdullah University Hospital, Northern Jordan, between 2009 and 2019. Data were extracted from patients’ medical records and analyzed in patients treated with burr hole drainage (BHD). Univariate analysis was performed to identify correlations with age, laterality, and recurrence. Results A total of 172 CSDH patients were identified, of whom 128 (74.4%) were treated surgically. The mean age of patients treated with BHD (n = 108) was 60.9 years with a male-to-female ratio of 2.38:1. Headache was the most common presenting symptom (64.81%) and was significant in patients aged 41–64 years (p = 0.004), whereas muscle weakness and unsteady gait were significant in patients ≥ 65 years (p = 0.004 and p = 0.033, respectively). A higher pre-operative maximum thickness was associated with bilateral presentation (p = 0.001), whereas a higher pre-operative midline shift was associated with unilateral presentation (p = 0.027). Regarding CSDH recurrence, only a preoperative midline shift was significant (p = 0.021). Conclusion Clinical presentation was affected by age, as patients < 65 years commonly presented with headaches, whereas those ≥ 65 years presented with limb weakness, speech impairment, unsteady gait, and altered consciousness. BHD was the most utilized surgical option with low mortality and complication rates. Recurrence was only associated with a pre-operative midline shift.
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11
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Mohamed S, Villabona A, Kennion O, Padmananbhan R, Siddiqui A, Khan S, Prasad M, Mukerji N. Middle meningeal artery embolisation for chronic subdural haematomas: the first prospective UK study. Br J Neurosurg 2022; 36:786-791. [PMID: 35892289 DOI: 10.1080/02688697.2022.2097200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Background/Objectives: MMA embolisation has emerged in recent years as a safe endovascular treatment for chronic subdural haematoma. We report the first UK series of endovascular treatment of chronic subdural haematomas.Design: Prospective case series.Subjects: All adult patients referred with midline shift ≤10 mm and GCS ≥13 were considered. Patients had to be mobile with a standard origin of Middle Meningeal and Ophthalmic arteries. Patients with GCS < 13 or profound weakness (MRC grade ≤ 3) were treated with burr hole drainage and placement of subdural drains.Methods: Patients were recruited over a 14-month period from 25 October 2020 to 25 December 21 through our electronic referral system. Patients' demographics, pre-morbid modified Rankin Score (mRS), symptoms; anticoagulation and co-morbidities were prospectively collected. Suitability for endovascular treatment was discussed with the interventional neuroradiologist and neurosurgeon. SQUID-12 embolic material was used for all MMA embolisations, which was performed under general anaesthetic. Baseline CT/MRI characteristics were collected. Further imaging was obtained at 7, 21, 90 and 180 days. Clinical assessment and mRS was completed at three months.Results: Fifteen patients underwent endovascular embolisation of MMA in the study period. Of these 13 were male, median age was 79 years. Median length of stay was four days. Follow-up CT at three months has demonstrated significant reduction in both midline shift (p = 0.002) and maximum thickness of haematoma (p = 0.001). Nine patients had reached the three months' follow-up period. All of them had complete or near-complete resolution of the CSDH. One patient required surgical rescue at two months post procedure due to progression of CSDH. We report one mortality due to COVID-19.Conclusions: For select patients, MMA embolisation is a safe alternative treatment option for chronic subdural haematoma. As we gain more experience, the procedure could be performed under local anaesthetic.
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Affiliation(s)
- Saffwan Mohamed
- Department of Neurosurgery, James Cook University Hospital, Middlesbrough, UK
| | - Alvaro Villabona
- Department of Neurosurgery, James Cook University Hospital, Middlesbrough, UK
| | - Oliver Kennion
- Department of Neurosurgery, James Cook University Hospital, Middlesbrough, UK
| | - Rajeev Padmananbhan
- Department of Neuroradiology, James Cook University Hospital, Middlesbrough, UK
| | - Aslam Siddiqui
- Department of Neuroradiology, James Cook University Hospital, Middlesbrough, UK
| | - Shahid Khan
- Department of Neurosurgery, James Cook University Hospital, Middlesbrough, UK
| | - Manjunath Prasad
- Department of Neurosurgery, James Cook University Hospital, Middlesbrough, UK
| | - Nitin Mukerji
- Department of Neurosurgery, James Cook University Hospital, Middlesbrough, UK
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Anagnostopoulos V, Brotis AG, Tzerefos C, Charalambidou A, Tasiou A, Karavelis A, Paterakis KN. Valve-controlled chronic subdural hematoma drainage: A feasibility study. BRAIN & SPINE 2022; 2:101693. [PMID: 36506285 PMCID: PMC9729815 DOI: 10.1016/j.bas.2022.101693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 11/09/2022] [Accepted: 11/16/2022] [Indexed: 06/17/2023]
Abstract
INTRODUCTION Pneumocephalus after chronic subdural hematoma (CSDH) evacuation is a potential predictor of hematoma recurrence. RESEARCH QUESTION To study the feasibility and safety of a novel CSDH evacuation technique using a valve-controlled method to avoid pneumocephalus. MATERIAL AND METHODS In a retrospective case series, we evacuated CSDH using very low-pressure valve-controlled drains and recorded the neurological, radiological, and functional outcomes. Patients with primary CSDH, without previous neurosurgical intervention, and who did not receive antiplatelet or anticoagulant therapy the week prior to the index surgery, were included in the study. Exclusion criteria were the evacuation with other treatment techniques and incomplete data files. Patients were assessed according to the Bender grading system to record the neurological status. The hematoma volume was estimated using the formula for ellipsoid volumes. RESULTS Thirty-six patients with a mean age of 73 years (±9 years) fulfilled our eligibility criteria. Our technique was effective since it decreased the CSDH volume from 141 ml (IQR 97 ml) to 20.6 ml (IQR 26.59 ml; p < 0.001) and improved the neurological status according to the Bender grading system from two (IQR 0.25) to 1 (IQR 0). However, pneumocephalus and hematoma recurrence occurred in one case each (2.8%). At six months, all patients returned to their previous status, except for two patients (5.6%) who died due to irrelevant pathologies. CONCLUSIONS Valve-controlled CSDH evacuation aiming to decrease the postoperative pneumocephalus and hematoma recurrence constitutes an effective and safe alternative. However, larger randomized controlled studies are required to establish its role in CSDH management.
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Affiliation(s)
| | - Alexandros G. Brotis
- Department of Neurosurgery, Faculty of Medicine, University of Thessaly, Larisa, Greece
| | - Christos Tzerefos
- Department of Neurosurgery, Faculty of Medicine, University of Thessaly, Larisa, Greece
| | | | - Anastasia Tasiou
- Department of Neurosurgery, Faculty of Medicine, University of Thessaly, Larisa, Greece
| | - Antonios Karavelis
- Department of Neurosurgery, Faculty of Medicine, University of Thessaly, Larisa, Greece
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13
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Wu L, Ou Y, Liu W. Letter to the Editor. Subdural drainage time in different treatment strategies of CSDH. J Neurosurg 2022; 137:1562-1563. [PMID: 35901734 DOI: 10.3171/2022.5.jns221135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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14
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Mignucci-Jiménez G, Matos-Cruz AJ, Abramov I, Hanalioglu S, Kovacs MS, Preul MC, Feliciano-Valls CE. Puerto Rico Recurrence Scale: Predicting chronic subdural hematoma recurrence risk after initial surgical drainage. Surg Neurol Int 2022; 13:230. [PMID: 35855136 PMCID: PMC9282733 DOI: 10.25259/sni_240_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 05/05/2022] [Indexed: 11/04/2022] Open
Abstract
Background: Chronic subdural hematoma (CSDH) commonly affects older individuals and is associated with a relatively high rate of recurrence after surgery. Many studies have created grading systems to identify patients at high risk of CSDH recurrence after the initial surgery. However, no system has been adopted widely. The authors present the first CSDH grading system created from a population-based single-center data set. Methods: A single-center Puerto Rican population-based retrospective analysis was performed on consecutive patients treated for a CSDH at a designated institution from July 1, 2017 to December 31, 2019. Univariate and multivariate analyses were used to create a CSDH recurrence grading scale. Retrospective validation was conducted on this sample population. Results: The study included 428 patients. Preoperative midline shift, postoperative midline shift, and size of postoperative subdural space differed between the recurrence and nonrecurrence groups (P = 0.03, 0.002, and 0.002, respectively). A multivariate analysis was used to create a 10-point grading scale comprising four independent variables. Recurrence rates progressively increased from the low-risk (0–3 points) to high-risk (8–10 points) groups (2.9% vs. 20.3%; P < 0.001). Conclusion: A 10-point grading scale for CSDH recurrence was developed with four components: preoperative midline shift (≤1 and >1 cm), laterality (bilateral, unilateral-right, and unilateral-left), size of postoperative subdural space (≤1.6 and >1.6 cm), and pneumocephalus (present or absent). Patients who scored higher on the scale had a higher risk of recurrence. This CSDH grading scale has implications for Puerto Rico and the general population as the elderly population increases worldwide.
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Affiliation(s)
- Giancarlo Mignucci-Jiménez
- Department of Surgery, Neurosurgery Section, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico, United States,
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona, United States,
| | - Alejandro J. Matos-Cruz
- Department of Surgery, Neurosurgery Section, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico, United States,
- Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, Pennsylvania, United States
| | - Irakliy Abramov
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona, United States,
| | - Sahin Hanalioglu
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona, United States,
| | - Melissa S. Kovacs
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona, United States,
| | - Mark C. Preul
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona, United States,
| | - Caleb E. Feliciano-Valls
- Department of Surgery, Neurosurgery Section, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico, United States,
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15
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Ou Y, Yu X, Wu L, Zhang D, Liu W. Recurrence of Chronic Subdural Hematoma Is Independent of ABO Blood Type: A Retrospective Cohort Study. Front Neurol 2022; 13:833958. [PMID: 35669879 PMCID: PMC9163317 DOI: 10.3389/fneur.2022.833958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 04/22/2022] [Indexed: 11/13/2022] Open
Abstract
Objective A previous study with a limited number of patients has shown that blood type A was a risk factor in the recurrence of CSDH. The primary objective of this study was to investigate the association between the recurrence of CSDH and ABO blood type based on a larger sample size. Methods The authors reviewed in-patients with symptomatic CSDH from August 2011 to August 2021. Hospitalization information and data on long-term outcomes and recurrence among these patients were gathered. For all clinical variables, numbers (percentages) and mean ± standard deviations were used for categorical and continuous variables, respectively. For intergroup comparisons, the χ2 test or one-way ANOVA was carried out. Multivariable logistic regression analyses were performed to identify the association between CSDH recurrence and blood types. Results We included 1,556 inpatients in this study. The recurrence rate of CSDH showed no differences among different blood types. In the multivariable logistic regression analyses, ABO blood type (A: OR, 1.064; 95% CI, 0.467-2.851, p = 0.793; B: OR, 0.682, 95% CI, 0.315-1.269, p = 0.164; AB: OR, 0.537, 95% CI, 0.426-1.861, p = 0.357) was not a significantly independent predictor of CSDH recurrence. Conclusions Our study demonstrated that ABO blood type was not a risk factor in the recurrence of CSDH. Thus, we should not pay too much attention to ABO blood type in terms of CSDH recurrence.
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Affiliation(s)
- Yunwei Ou
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, Beihang University, Beijing, China
| | - Xiaofan Yu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Liang Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dong Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Weiming Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Neurological Center, People's Hospital of Ningxia Hui Autonomous Region, Yinchuan, China
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16
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Hamou H, Alzaiyani M, Pjontek R, Kremer B, Albanna W, Ridwan H, Clusmann H, Hoellig A, Veldeman M. Risk factors of recurrence in chronic subdural hematoma and a proposed extended classification of internal architecture as a predictor of recurrence. Neurosurg Rev 2022; 45:2777-2786. [PMID: 35461433 PMCID: PMC9349063 DOI: 10.1007/s10143-022-01790-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 03/30/2022] [Accepted: 04/12/2022] [Indexed: 12/03/2022]
Abstract
Chronic subdural hematomas (cSDHs) constitute one of the most prevalent intracranial disease entities requiring surgical treatment. Although mostly taking a benign course, recurrence after treatment is common and associated with additional morbidity and costs. Aim of this study was to develop hematoma-specific characteristics associated with risk of recurrence. All consecutive patients treated for cSDH in a single university hospital between 2015 and 2019 were retrospectively considered for inclusion. Size, volume, and midline shift were noted alongside relevant patient-specific factors. We applied an extended morphological classification system based on internal architecture in CT imaging consisting of eight hematoma subtypes. A logistic regression model was used to assess the classification’s performance on predicting hematoma recurrence. Recurrence was observed in 122 (32.0%) of 381 included patients. Apart from postoperative depressed brain volume (OR 1.005; 95% CI 1.000 to 1.010; p = 0.048), neither demographic nor factors related to patient comorbidity affected recurrence. The extended hematoma classification was identified as a significant predictor of recurrence (OR 1.518; 95% CI 1.275 to 1.808; p < 0.001). The highest recurrence rates were observed in hematomas of the homogenous (isodense: 41.4%; hypodense: 45.0%) and sedimented (50.0%) types. Our results support that internal architecture subtypes might represent stages in the natural history of chronic subdural hematoma. Detection and treatment at a later stage of spontaneous repair can result in a reduced risk of recurrence. Based on their high risk of recurrence, we advocate follow-up after treatment of sedimented and homogenous hematomas.
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Affiliation(s)
- Hussam Hamou
- Department of Neurosurgery, RWTH Aachen University Hospital, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Mohamed Alzaiyani
- Department of Neurosurgery, RWTH Aachen University Hospital, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Rastislav Pjontek
- Department of Neurosurgery, RWTH Aachen University Hospital, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Benedikt Kremer
- Department of Neurosurgery, RWTH Aachen University Hospital, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Walid Albanna
- Department of Neurosurgery, RWTH Aachen University Hospital, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Hani Ridwan
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany
| | - Hans Clusmann
- Department of Neurosurgery, RWTH Aachen University Hospital, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Anke Hoellig
- Department of Neurosurgery, RWTH Aachen University Hospital, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Michael Veldeman
- Department of Neurosurgery, RWTH Aachen University Hospital, Pauwelsstrasse 30, 52074, Aachen, Germany.
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17
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Guo H, Fang X, Guo H. Letter to the Editor. A new predictor of chronic subdural hematoma recurrence. J Neurosurg 2022:1-2. [PMID: 35148510 DOI: 10.3171/2021.12.jns212797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Heng Guo
- 1General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Xin Fang
- 2Chongqing Medical and Pharmaceutical College, Chongqing, China
| | - Hao Guo
- 3Southwest Hospital, Army Medical University, Chongqing, China
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18
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Kerttula S, Huttunen J, Leinonen V, Kämäräinen OP, Danner N. The effect of antithrombotic therapy on the recurrence and outcome of chronic subdural hematoma after burr-hole craniostomy in a population-based cohort. Acta Neurochir (Wien) 2022; 164:2699-2708. [PMID: 35972559 PMCID: PMC9519695 DOI: 10.1007/s00701-022-05337-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 08/02/2022] [Indexed: 01/26/2023]
Abstract
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.
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Affiliation(s)
- Santtu Kerttula
- Institute of Clinical Medicine - Neurosurgery, University of Eastern Finland, Kuopio, Finland.
| | - Jukka Huttunen
- Neurocenter - Neurosurgery, Kuopio University Hospital, Kuopio, Finland
| | - Ville Leinonen
- Institute of Clinical Medicine - Neurosurgery, University of Eastern Finland, Kuopio, Finland
- Neurocenter - Neurosurgery, Kuopio University Hospital, Kuopio, Finland
| | - Olli-Pekka Kämäräinen
- Institute of Clinical Medicine - Neurosurgery, University of Eastern Finland, Kuopio, Finland
- Neurocenter - Neurosurgery, Kuopio University Hospital, Kuopio, Finland
| | - Nils Danner
- Neurocenter - Neurosurgery, Kuopio University Hospital, Kuopio, Finland
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Oh HJ, Seo Y, Choo YH, Kim YI, Kim KH, Kwon SM, Lee MH, Chong K. Clinical Characteristics and Current Managements for Patients with Chronic Subdural Hematoma : A Retrospective Multicenter Pilot Study in the Republic of Korea. J Korean Neurosurg Soc 2021; 65:255-268. [PMID: 34727680 PMCID: PMC8918242 DOI: 10.3340/jkns.2021.0138] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 07/21/2021] [Indexed: 11/27/2022] Open
Abstract
Objective Chronic subdural hematoma (CSDH) is a common disease in neurosurgical departments, but optimal perioperative management guidelines have not yet been established. We aimed to assess the current clinical management and outcomes for CSDH patients and identify prognostic factors for CSDH recurrence.
Methods We enrolled a total of 293 consecutive patients with CSDH who underwent burr hole craniostomy at seven institutions in 2018. Clinical and surgery-related characteristics and surgical outcomes were analyzed. The cohort included 208 men and 85 women.
Results The median patient age was 75 years. Antithrombotic agents were prescribed to 105 patients. History of head trauma was identified in 59% of patients. Two hundred twenty-seven of 293 patients (77.5%) had unilateral hematoma and 46.1% had a homogenous hematoma type. About 70% of patients underwent surgery under general anesthesia, and 74.7% underwent a single burr hole craniostomy surgery. Recurrence requiring surgery was observed in 17 of 293 patients (5.8%), with a median of 32 days to recurrence. The postoperative complication rate was 4.1%. In multivariate analysis, factors associated with CSDH recurrence were separated hematoma type (odds ratio, 3.906; p=0.017) and patient who underwent surgery under general anesthesia had less recurrence (odds ratio, 0.277; p=0.017).
Conclusion This is the first retrospective multicenter generalized cohort pilot study in the Republic of Korea as a first step towards the development of Korean clinical practice guidelines for CSDH. The type of hematoma and anesthesia was associated with CSDH recurrence. Although the detailed surgical method differs depending on the institution, the surgical treatment of CSDH was effective. Further studies may establish appropriate management guidelines to minimize CSDH recurrence.
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Affiliation(s)
- Hyuk-Jin Oh
- Neurotrauma Clinical Practice Guidelines Committee of the Korean Neurotraumatology Society (KNTS-NCPGC), Seoul, Korea.,Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, College of Medicine, Soonchunhyang University, Cheonan, Korea
| | - Youngbeom Seo
- Neurotrauma Clinical Practice Guidelines Committee of the Korean Neurotraumatology Society (KNTS-NCPGC), Seoul, Korea.,Department of Neurosurgery, Yeungnam University Hospital, Yeungnam Universtiy College of Medicine, Daegu, Korea
| | - Yoon-Hee Choo
- Department of Neurosurgery, Yeungnam University Hospital, Yeungnam Universtiy College of Medicine, Daegu, Korea.,Department of Intensive Care, Seoul National University Hospital, Seoul, Korea
| | - Young Il Kim
- Neurotrauma Clinical Practice Guidelines Committee of the Korean Neurotraumatology Society (KNTS-NCPGC), Seoul, Korea.,Department of Neurosurgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kyung Hwan Kim
- Neurotrauma Clinical Practice Guidelines Committee of the Korean Neurotraumatology Society (KNTS-NCPGC), Seoul, Korea.,Department of Neurosurgery, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Sae Min Kwon
- Neurotrauma Clinical Practice Guidelines Committee of the Korean Neurotraumatology Society (KNTS-NCPGC), Seoul, Korea.,Department of Neurosurgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Min Ho Lee
- Neurotrauma Clinical Practice Guidelines Committee of the Korean Neurotraumatology Society (KNTS-NCPGC), Seoul, Korea.,Department of Neurosurgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kyuha Chong
- Neurotrauma Clinical Practice Guidelines Committee of the Korean Neurotraumatology Society (KNTS-NCPGC), Seoul, Korea.,Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea.,Neurological Institute, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
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20
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Shlobin NA, Kedda J, Wishart D, Garcia RM, Rosseau G. Surgical Management of Chronic Subdural Hematoma in Older Adults: A Systematic Review. J Gerontol A Biol Sci Med Sci 2021; 76:1454-1462. [PMID: 33220683 DOI: 10.1093/gerona/glaa293] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Chronic subdural hematoma (cSDH) is a form of intracranial hemorrhage common in older adults. Optimal treatment remains controversial. We conducted a systematic review to identify surgical thresholds, characterize outcomes, and delineate critical considerations in the surgical management of older adults in order to summarize the evidence supporting the best contemporary management of cSDH. METHODS A systematic review exploring surgical management of cSDH among individuals aged 65 years and older was conducting by searching the PubMed, Embase, and Scopus databases for articles in English. Abstracts from articles were read and selected for full-text review according to a priori criteria. Relevant full-text articles were analyzed for bibliographic data, aim, study design, population, interventions, and outcomes. RESULTS Of 1473 resultant articles, 21 were included. Surgery rationale was case-by-case for symptomatic patients with cSDH. Surgery was superior to conservative management and promoted equivalent neurologic outcomes and rates of complications. Recurrence and reoperation rates in older adults were similar to younger individuals. Some studies reported higher mortality rates for older adults, while others reported no difference. Anticoagulation or antiplatelet agent use did not seem to be associated with poorer outcomes in older adults. CONCLUSIONS Surgery for cSDH in older adults leads to favorable neurologic outcomes without increased risk of overall complications, recurrence, or reoperation compared to younger patients. However, older adults may be at increased risk for mortality after surgery. It is important to determine use of anticoagulant or antiplatelet agents in older adults to optimally manage patients with cSDH.
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Affiliation(s)
- Nathan A Shlobin
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jayanidhi Kedda
- Department of Neurosurgery, George Washington University School of Medicine & Health Sciences, Washington, District of Columbia
| | - Danielle Wishart
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Roxanna M Garcia
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Gail Rosseau
- Department of Neurosurgery, George Washington University School of Medicine & Health Sciences, Washington, District of Columbia
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21
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Petrella L, Muscas G, Montemurro VM, Lastrucci G, Fainardi E, Pansini G, Della Puppa A. Use of the Subdural Hematoma in the Elderly (SHE) Score to Predict 30-Day Mortality After Chronic Subdural Hematoma Evacuation. World Neurosurg 2021; 157:e294-e300. [PMID: 34648990 DOI: 10.1016/j.wneu.2021.10.072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 10/01/2021] [Accepted: 10/04/2021] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Luca Petrella
- Department of Neurosurgery, Department of Neuroscience, Psychology, Drug Area and Child Health (NEUROFARBA), Florence, Italy
| | - Giovanni Muscas
- Department of Neurosurgery, Department of Neuroscience, Psychology, Drug Area and Child Health (NEUROFARBA), Florence, Italy.
| | - Vita Maria Montemurro
- Department of Neurosurgery, Department of Neuroscience, Psychology, Drug Area and Child Health (NEUROFARBA), Florence, Italy
| | - Giancarlo Lastrucci
- Department of Neurosurgery, Department of Neuroscience, Psychology, Drug Area and Child Health (NEUROFARBA), Florence, Italy
| | - Enrico Fainardi
- Neuroradiology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Careggi University Hospital, Florence, Italy
| | - Gastone Pansini
- Department of Neurosurgery, Department of Neuroscience, Psychology, Drug Area and Child Health (NEUROFARBA), Florence, Italy
| | - Alessandro Della Puppa
- Department of Neurosurgery, Department of Neuroscience, Psychology, Drug Area and Child Health (NEUROFARBA), Florence, Italy
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22
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Gong Z, Zhan D, Nie M, Li X, Gao C, Liu X, Xiang T, Yuan J, Jiang W, Huang J, Quan W, Wang D, Tian Y, Yuan H, Zhang J, Jiang R. Dexamethasone enhances the efficacy of atorvastatin in inhibiting excessively inflammation-induced abnormal angiogenesis by regulating macrophages. J Neuroinflammation 2021; 18:203. [PMID: 34526068 PMCID: PMC8444603 DOI: 10.1186/s12974-021-02257-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 08/27/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We have recently showed that atorvastatin (ATO) combined with low dose of dexamethasone (DEX) was more efficacious in treating patients with chronic subdural haematoma (CSDH) than ATO monotherapy. This study was designed to investigate the underlying mechanisms of the improved efficacy of this combined therapy. METHODS Mass spectrometry was performed to quantitatively detect drugs in haematoma fluids and serum samples from CSDH patients and also in cultured macrophages after treatment with either ATO alone or in combination with DEX. The differentiation and apoptosis of macrophages were evaluated using flow cytometry. The expression of cytokines, chemokines and angiogenesis-related proteins was evaluated using proteome profile arrays, immunoblots and ELISA, respectively. RESULTS ATO was detected in haematoma fluids and serum samples, whose levels were increased significantly in samples collected from patients treated with both ATO and DEX. ATO was also increased in cultured macrophages treated with ATO and DEX. The numbers of M1-polarized macrophages were higher than the M2 phenotype in the haematoma fluids of patients. Cultured macrophages treated with ATO and DEX had reduced numbers of M1-polarized macrophages, increased numbers of M2-polarized macrophages as compared to monotherapies, and decreased rate of apoptosis induced by high-dose DEX. DEX enhanced the anti-inflammatory and anti-angiogenic activity of ATO by suppressing VEGFA and other inflammatory angiogenic factors. Consistent with the finding, patients responded well to the drug treatments had lower serum levels of VEGFA. CONCLUSIONS We have shown for the first time that ATO given orally was detected in CSDH haematoma fluids. DEX enhances the anti-inflammatory and anti-angiogenic effects of ATO, primarily by increasing the presence of ATO in haematoma and macrophages and by regulating the functions of macrophages.
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Affiliation(s)
- Zhitao Gong
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, 300052, China.,Tianjin Neurological Institute, Key Laboratory of Post-neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China.,Department of Rehabilitation Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Daqiang Zhan
- Department of Pharmacy, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, China.,Department of pharmacy, Second Affiliated Hospital of Hainan Medical University, Hainan, China
| | - Meng Nie
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, 300052, China.,Tianjin Neurological Institute, Key Laboratory of Post-neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Xiaochun Li
- Tianjin Neurological Institute, Key Laboratory of Post-neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China.,Department of Pharmacy, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, China
| | - Chuang Gao
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, 300052, China.,Tianjin Neurological Institute, Key Laboratory of Post-neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Xuanhui Liu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, 300052, China.,Tianjin Neurological Institute, Key Laboratory of Post-neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Tangtang Xiang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, 300052, China.,Tianjin Neurological Institute, Key Laboratory of Post-neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Jiangyuan Yuan
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, 300052, China.,Tianjin Neurological Institute, Key Laboratory of Post-neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Weiwei Jiang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, 300052, China.,Tianjin Neurological Institute, Key Laboratory of Post-neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Jinhao Huang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, 300052, China.,Tianjin Neurological Institute, Key Laboratory of Post-neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Wei Quan
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, 300052, China.,Tianjin Neurological Institute, Key Laboratory of Post-neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Dong Wang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, 300052, China.,Tianjin Neurological Institute, Key Laboratory of Post-neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Ye Tian
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, 300052, China.,Tianjin Neurological Institute, Key Laboratory of Post-neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China
| | - Hengjie Yuan
- Tianjin Neurological Institute, Key Laboratory of Post-neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China. .,Department of Pharmacy, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, China.
| | - Jianning Zhang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, 300052, China. .,Tianjin Neurological Institute, Key Laboratory of Post-neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China.
| | - Rongcai Jiang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin Medical University, Tianjin, 300052, China. .,Tianjin Neurological Institute, Key Laboratory of Post-neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin, Tianjin, China.
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23
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Tosaka M. Letter: Subdural Pneumocephalus Aspiration Reduces Recurrence of Chronic Subdural Hematoma. Oper Neurosurg (Hagerstown) 2021; 21:E67-E68. [PMID: 33822204 DOI: 10.1093/ons/opab078] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Masahiko Tosaka
- Department of Neurosurgery Gunma University Graduate School of Medicine Maebashi, Gunma, Japan
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24
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Xu X, Wang D, Han Z, Wang B, Gao W, Fan Y, Li F, Zhou Z, Gao C, Xiong J, Zhou S, Zhang S, Yang G, Jiang R, Zhang J. 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. Brain Res Bull 2021; 172:108-119. [PMID: 33932488 DOI: 10.1016/j.brainresbull.2021.04.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 04/23/2021] [Accepted: 04/24/2021] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Xin Xu
- Department of Neurosurgery, Tianjin Medical University General Hospital, 154 Anshan Road, Tianjin, 300052, China; Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, 154 Anshan Road, Tianjin, 300052, China; Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Beijing, 100053, China
| | - Dong Wang
- Department of Neurosurgery, Tianjin Medical University General Hospital, 154 Anshan Road, Tianjin, 300052, China; Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, 154 Anshan Road, Tianjin, 300052, China
| | - Zhenying Han
- Department of Neurosurgery, Tianjin Medical University General Hospital, 154 Anshan Road, Tianjin, 300052, China; Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, 154 Anshan Road, Tianjin, 300052, China
| | - Bo Wang
- Department of Neurosurgery, Tianjin Medical University General Hospital, 154 Anshan Road, Tianjin, 300052, China; Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, 154 Anshan Road, Tianjin, 300052, China
| | - Weiwei Gao
- Department of Neurology, Tianjin Huanhu Hospital, 6 Jizhao Road, Tianjin, 300350, China
| | - Yueshan Fan
- Department of Neurosurgery, Tianjin Medical University General Hospital, 154 Anshan Road, Tianjin, 300052, China; Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, 154 Anshan Road, Tianjin, 300052, China
| | - Fanjian Li
- Department of Neurosurgery, Tianjin Medical University General Hospital, 154 Anshan Road, Tianjin, 300052, China; Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, 154 Anshan Road, Tianjin, 300052, China
| | - Ziwei Zhou
- Department of Neurosurgery, Tianjin Medical University General Hospital, 154 Anshan Road, Tianjin, 300052, China; Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, 154 Anshan Road, Tianjin, 300052, China
| | - Chuang Gao
- Department of Neurosurgery, Tianjin Medical University General Hospital, 154 Anshan Road, Tianjin, 300052, China; Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, 154 Anshan Road, Tianjin, 300052, China
| | - Jianhua Xiong
- Department of Neurosurgery, Tianjin Medical University General Hospital, 154 Anshan Road, Tianjin, 300052, China; Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, 154 Anshan Road, Tianjin, 300052, China
| | - Shuai Zhou
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, 154 Anshan Road, Tianjin, 300052, China
| | - Shu Zhang
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, 154 Anshan Road, Tianjin, 300052, China
| | - Guili Yang
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, 154 Anshan Road, Tianjin, 300052, China
| | - Rongcai Jiang
- Department of Neurosurgery, Tianjin Medical University General Hospital, 154 Anshan Road, Tianjin, 300052, China; Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, 154 Anshan Road, Tianjin, 300052, China.
| | - Jianning Zhang
- Department of Neurosurgery, Tianjin Medical University General Hospital, 154 Anshan Road, Tianjin, 300052, China; Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, 154 Anshan Road, Tianjin, 300052, China.
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25
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Davidson B, Narvacan K, Munoz DG, Rotondo F, Kovacs K, Zhang S, Cusimano MD. The Crucial Role of Eosinophils in the Life Cycle, Radiographical Architecture, and Risk of Recurrence of Chronic Subdural Hematomas. Neurotrauma Rep 2021; 2:76-83. [PMID: 34223547 PMCID: PMC8240825 DOI: 10.1089/neur.2020.0036] [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] [Indexed: 01/21/2023] Open
Abstract
Chronic subdural hematomas (CSDHs) are a common neurological condition, whose incidence is expected to increase with an aging population. Although surgical evacuation is the mainstay of treatment, it results in a recurrence requiring reoperation (RrR) in 3-30% of cases. Recurrence is thought to be driven by a combination of inflammatory and angiogenic processes occurring within the CSDH outer membrane. Pathological specimens of 72 primary CSDHs were examined for eosinophilic infiltrate. For each case, the pre-operative computed tomography (CT) scan was graded according to the Nakaguchi grading scheme as homogeneous, laminar, separated, or trabecular. Rate of RrR was compared based on eosinophilic infiltrate and CT grade. A dense eosinophilic infiltrate was observed in 22% of specimens. The rate of RrR among specimens with a dense eosinophilic infiltrate was 0%, whereas it was 14.3% among specimens without a dense eosinophilic infiltrate. Incidence among homogeneous, laminar, separated, and trabecular CT subtypes was 4%, 27%, 58%, and 24%, respectively. A dense eosinophilic infiltrate found within the outer membrane of a CSDH may be a marker of hematoma maturation, signaling a transition toward healing and fibrosis, and a lower risk of RrR.
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Affiliation(s)
- Benjamin Davidson
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Karl Narvacan
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - David G Munoz
- Division of Pathology, Department of Laboratory Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Fabio Rotondo
- Division of Pathology, Department of Laboratory Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kalman Kovacs
- Division of Pathology, Department of Laboratory Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Stanley Zhang
- Injury Prevention Research Office, Division of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Michael D Cusimano
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Injury Prevention Research Office, Division of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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26
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Kellogg RT, Vargas J, Barros G, Sen R, Bass D, Mason JR, Levitt M. Segmentation of Chronic Subdural Hematomas Using 3D Convolutional Neural Networks. World Neurosurg 2020; 148:e58-e65. [PMID: 33359736 DOI: 10.1016/j.wneu.2020.12.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 11/30/2020] [Accepted: 12/01/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Chronic subdural hematomas (cSDHs) are an increasingly prevalent neurologic disease that often requires surgical intervention to alleviate compression of the brain. Management of cSDHs relies heavily on computed tomography (CT) imaging, and serial imaging is frequently obtained to help direct management. The volume of hematoma provides critical information in guiding therapy and evaluating new methods of management. We set out to develop an automated program to compute the volume of hematoma on CT scans for both pre- and postoperative images. METHODS A total of 21,710 images (128 CT scans) were manually segmented and used to train a convolutional neural network to automatically segment cSDHs. We included both pre- and postoperative coronal head CTs from patients undergoing surgical management of cSDHs. RESULTS Our best model achieved a DICE score of 0.8351 on the testing dataset, and an average DICE score of 0.806 ± 0.06 on the validation set. This model was trained on the full dataset with reduced volumes, a network depth of 4, and postactivation residual blocks within the context modules of the encoder pathway. Patch trained models did not perform as well and decreasing the network depth from 5 to 4 did not appear to significantly improve performance. CONCLUSIONS We successfully trained a convolutional neural network on a dataset of pre- and postoperative head CTs containing cSDH. This tool could assist with automated, accurate measurements for evaluating treatment efficacy.
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Affiliation(s)
- Ryan T Kellogg
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA.
| | - Jan Vargas
- Division of Neurosurgery, Prisma Health, Greenville, South Carolina, USA
| | - Guilherme Barros
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Rajeev Sen
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - David Bass
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - J Ryan Mason
- Department of Radiology, University of Washington, Seattle, Washington, USA
| | - Michael Levitt
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
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27
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Won SY, Dubinski D, Behmanesh B, Bernstock JD, Keil F, Freiman T, Konczalla J, Seifert V, Gessler F. Supervised Valsalva Maneuver after Burr Hole Evacuation of Chronic Subdural Hematomas: A Prospective Cohort Study. J Neurotrauma 2020; 38:911-917. [PMID: 33081586 DOI: 10.1089/neu.2020.7391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Research on chronic subdural hematoma (cSDH) management has primarily focused on potential recurrence after surgical evacuation. Herein, we present a novel postoperative/non-invasive treatment that includes a supervised Valsalva maneuver (SVM), which may serve to reduce SDH recurrence. Accordingly, the aims of the study were to investigate the effects of SVM on SDH recurrence rates and functional outcomes. A prospective study was conducted from December 2016 until December 2019 at the Goethe University Hospital Frankfurt. Of the 204 adult patients with surgically treated cSDH who had subdural drains placed, 94 patients were assigned to the SVM group and 82 patients were assigned to the control group. The SVM was performed by having patients blow into a self-made SVM device at least two times/h for 12 h/day. The primary end-point was SDH recurrence rate, while secondary outcomes were morbidity and functional outcomes at 3 months of follow-up. SDH recurrence was observed in 16 of 94 patients (17%) in the SVM group, which was a significant reduction as compared with the control group, which had 24 of 82 patients (29.3%; p = 0.05) develop recurrent SDHs. Further, the infection rate (e.g., pneumonia) was significantly lower in the SVM group (1.1%) than in the control group (13.4%; p < 0.001; odds ratio [OR] 0.1). At the 3-month follow-up, 85 of 94 patients (90.4%) achieved favorable outcomes in the SVM group compared with 62 of 82 patients (75.6%) in the control group (p = 0.008; OR 3.0). Independent predictors for favorable outcome at follow-up were age (OR 0.9) and infection (OR 0.2). SVM appears to be safe and effective in the post-operative management of cSDHs, reducing both recurrence rates and infections after surgical evacuation, thereby resulting in favorable outcomes at follow-up.
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Affiliation(s)
- Sae-Yeon Won
- Department of Neurosurgery, University Hospital, and Goethe University, Frankfurt, Germany
| | - Daniel Dubinski
- Department of Neurosurgery, University Hospital, and Goethe University, Frankfurt, Germany
| | - Bedjan Behmanesh
- Department of Neurosurgery, University Hospital, and Goethe University, Frankfurt, Germany
| | | | - Fee Keil
- Department of Neurosurgery, Brigham and Women`s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Thomas Freiman
- Department of Neurosurgery, University Hospital, and Goethe University, Frankfurt, Germany
| | - Juergen Konczalla
- Department of Neurosurgery, University Hospital, and Goethe University, Frankfurt, Germany
| | - Volker Seifert
- Department of Neurosurgery, University Hospital, and Goethe University, Frankfurt, Germany
| | - Florian Gessler
- Department of Neurosurgery, University Hospital, and Goethe University, Frankfurt, Germany
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28
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Fujisawa N, Oya S, Yoshida S, Tsuchiya T, Nakamura T, Indo M, Matsui T. A Prospective Randomized Study on the Preventive Effect of Japanese Herbal Kampo Medicine Goreisan for Recurrence of Chronic Subdural Hematoma. Neurol Med Chir (Tokyo) 2020; 61:12-20. [PMID: 33208583 PMCID: PMC7812313 DOI: 10.2176/nmc.oa.2020-0287] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Although the recurrence of chronic subdural hematoma (CSDH) after surgical treatment significantly affects the patients' quality of life, the recurrence rate has not improved in decades. Goreisan, a Japanese herbal Kampo medicine, promotes the hydragogue effect and has been empirically used in the treatment of CSDH in Japan. We conducted a prospective randomized study to investigate whether Goreisan treatment decreases the recurrence rate of CSDH. Between March 2013 and December 2018, a total of 224 patients who underwent initial burr hole surgery for CSDH were randomly assigned to receive Goreisan for 3 months (Group G) or no medication (Group N). The primary endpoint was symptomatic recurrence within 3 months postoperatively, and the secondary endpoint was complications, including the adverse effects of Goreisan. Of 224 randomized patients, 208 were included in the final analysis (104 in Group G and 104 in Group N). The overall recurrence rate was 9.1% (19/208). The recurrence rate of Group G was lower than that of Group N (5.8% vs 12.5%, P = 0.09), but the difference was not statistically significant. However, a significant preventive effect of Goreisan was found in 145 patients with high-risk computed tomography (CT) features, namely, homogeneous and separated types (5.6% vs 17.6%, P = 0.04). Although the present study did not prove the beneficial effect of Goreisan treatment, it suggested the importance of selecting patients with an increased risk of recurrence. A subset of patients whose hematoma showed homogeneous and separated patterns on CT image might benefit from Goreisan treatment.
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Affiliation(s)
- Naoaki Fujisawa
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University
| | - Soichi Oya
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University
| | - Shinsuke Yoshida
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University
| | - Tsukasa Tsuchiya
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University
| | - Takumi Nakamura
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University
| | - Masahiro Indo
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University
| | - Toru Matsui
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University
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Rauhala M, Helén P, Huhtala H, Heikkilä P, Iverson GL, Niskakangas T, Öhman J, Luoto TM. Chronic subdural hematoma-incidence, complications, and financial impact. Acta Neurochir (Wien) 2020; 162:2033-2043. [PMID: 32524244 PMCID: PMC7415035 DOI: 10.1007/s00701-020-04398-3] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 05/06/2020] [Indexed: 10/31/2022]
Abstract
OBJECTIVE To examine the population-based incidence, complications, and total, direct hospital costs of chronic subdural hematoma (CSDH) treatment in a neurosurgical clinic during a 26-year period. The aim was also to estimate the necessity of planned postoperative follow-up computed tomography (CT). METHODS A retrospective cohort (1990-2015) of adult patients living in Pirkanmaa, Finland, with a CSDH was identified using ICD codes and verified by medical records (n = 1148, median age = 76 years, men = 65%). Data collection was performed from medical records. To estimate the total, direct hospital costs, all costs from hospital admission until the last neurosurgical follow-up visit were calculated. All patients were followed until death or the end of 2017. The annual number of inhabitants in the Pirkanmaa Region was obtained from the Statistics Finland (Helsinki, Finland). RESULTS The incidence of CSDH among the population 80 years or older has increased among both operatively (from 36.6 to 91/100,000/year) and non-operatively (from 4.7 to 36.9/100,000/year) treated cases. Eighty-five percent (n = 978) underwent surgery. Routine 4-6 weeks' postoperative follow-up CT increased the number of re-operations by 18% (n = 49). Most of the re-operations (92%) took place within 2 months from the primary operation. Patients undergoing re-operations suffered more often from seizures (10%, n = 28 vs 3.9%, n = 27; p < 0.001), empyema (4.3%, n = 12 vs 1.1%, n = 8; p = 0.002), and pneumonia (4.7%, n = 13 vs 1.4%, n = 12; p = 0.008) compared with patients with no recurrence. The treatment cost for recurrent CSDHs was 132% higher than the treatment cost of non-recurrent CSDHs, most likely because of longer hospital stay for re-admissions and more frequent outpatient follow-up with CT. The oldest group of patients, 80 years or older, was not more expensive than the others, nor did this group have more frequent complications, besides pneumonia. CONCLUSIONS Based on our population-based study, the number of CSDH patients has increased markedly during the study period (1990-2015). Reducing recurrences is crucial for reducing both complications and costs. Greater age was not associated with greater hospital costs related to CSDH. A 2-month follow-up period after CSDH seems sufficient for most, and CT controls are advocated only for symptomatic patients.
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Ridwan S, Grote A, Simon M. In Reply to the Letter to the Editor Regarding "Surgical Treatment of Chronic Subdural Hematoma: Predicting Recurrence and Cure". World Neurosurg 2020; 139:650. [PMID: 32689659 DOI: 10.1016/j.wneu.2020.04.210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 04/27/2020] [Indexed: 11/16/2022]
Affiliation(s)
- Sami Ridwan
- Department of Neurosurgery, Bethel Clinic, Bielefeld, Germany.
| | - Alexander Grote
- Department of Neurosurgery, Bethel Clinic, Bielefeld, Germany
| | - Matthias Simon
- Department of Neurosurgery, Bethel Clinic, Bielefeld, Germany
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Brown NJ, Lien BV. Letter to the Editor Regarding “Surgical Treatment of Chronic Subdural Hematoma: Predicting Recurrence and Cure”. World Neurosurg 2020; 139:649. [DOI: 10.1016/j.wneu.2020.03.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 03/02/2020] [Indexed: 10/23/2022]
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