Outcomes of Surgical Evacuation of Chronic Subdural Hematoma in the Aged: Institutional Experience and Systematic Review

Long-term postoperative prognosis and associated risk factors of chronic subdural hematoma in the elderly

Surgical treatment for chronic subdural hematoma（CSDH）has contributed to good outcome. However, several recent studies have revealed that surgical outcomes for elderly patients were not decisively good. In this study, prognosis of CSDH patients in elderly were analyzed. This study included 232 CSDH patients who were treated in our department and 2 affiliated hospitals, and poor prognosis was defined as aggravation of modified Rankin scale (mRS) at examination comparing with that at discharge, or mRS 3 and higher at examination. We collected data from medical records and questionnaires on the following clinical characteristics of patients: age, sex, findings at admission, medication of antiplatelets and anticoagulants, radiological findings on computed tomography, recurrence, place of discharge, perioperative systemic complications, and mRS at discharge and at examination. The cut-off value of age for poor prognosis of all CSDH patients was 74 years old in this study. In multivariate analysis of all cases, age was prognostic factor for poor outcome:75 years old or higher（p=0.0002）. In this group, mRS at discharge(p=0.0184) and postoperative medical diseases(p<0.0001) were the risk factors of poor prognosis. In this present study, high age and activities of daily life（ADL） at discharge were significant prognostic factors for poor outcome of CSDH. Improvement of ADL at discharge with care for postoperative systemic complications and careful rehabilitation can contribute to good prognosis for CSDH in elderly patients.

Risk factors for recurrence of chronic subdural hematoma after surgical evacuation: a systematic review and meta-analysis

Chronic subdural hematoma (CSDH) is a common neurosurgical condition. Surgical evacuation has remained the primary treatment despite many advancements in the endovascular field. Regardless, recurrence requiring reoperation is commonly observed during the postoperative follow-up. Herein, we aimed to investigate risk factors for recurrence after surgical evacuation. A review of MEDLINE, EMBASE, Web of Science, and Scopus was conducted using the designed search string. Studies were reviewed based on the predefined eligibility criteria. Data regarding sixty potential risk factors along with operational information were extracted for analysis. A meta-analysis using the random-effect model was conducted, and each risk factor affecting the postoperative recurrence of CSDH was then evaluated and graded. A total of 198 records met the eligibility criteria. A total number of 8523 patients with recurrent CSDH and 56,096 with non-recurrent CSDH were included in the study. The recurrence rate after surgical evacuation was 12%. Fifteen preoperative, nine radiologic, four hematoma-related, and three operative and postoperative factors were associated with recurrence. Risk factors associated with recurrence after surgical evacuation are important in neurosurgical decision-making and treatment planning. Found risk factors in this study may be used as the basis for pre-operative risk assessment to choose patients who would benefit the most from surgical evacuation.

Subdural open drains as an effective and low-cost modality for the treatment of chronic subdural hematomas

PURPOSE

We present a series that describes the presenting features and clinical outcomes in patients with CSDH treated with a standardised technique and an open-drain placement.

METHODS

We reviewed the medical records of 155 consecutive patients at a single centre who underwent CSDH evacuation by placing burr holes, accompanied by intraoperative irrigation and a subdural Penrose drain between 2014 and 2018.

RESULTS

The mean age was 65.9 years, 81.9% were males. The most common clinical characteristics were an altered mental state (21.9%) and headache (12.9%). It was necessary to perform a second surgical intervention due to the evidence in the postoperative tomography of a residual hematoma in 10.3% of the cases; there were 2 cases of recurrence in 6 months (1.3%). Pneumonia (6.5%) and seizures (5.8%) were the most frequent medical complications. Intracranial infections accounted for 1.9%, and the mortality rate was 6.4% of cases.

CONCLUSIONS

We provided our experience with a low-cost and less-commonly used technique in the management of CSDH. This technique showed similar recurrence, mortality and intracranial infection rates to those reported in the literature for closed drainage systems. Additional studies will be required to assess this technique.

Awake transradial middle meningeal artery embolization and twist drill craniostomy for chronic subdural hematomas in the elderly: case series and technical note

BACKGROUND

Due to prohibitive perioperative risk factors, optimal treatment for chronic subdural hematomas (cSDH) in the elderly remains unclear. Minimally invasive techniques are a viable option and include bedside subdural evacuation port system (SEPS), as well as prevention of recurrence with middle meningeal artery (MMA) embolization. We present a case series of elderly patients undergoing combined transradial MMA embolization and bed-side craniostomy as primary treatment for cSDH.

METHODS

Patients 70 years and older from 2019 to 2020 that underwent single setting, awake transradial MMA embolization with concurrent SEPS placement under local anesthesia were included. Those with prior treatments, interventions performed under general anesthesia, or with less than 60-day follow-up were excluded. Descriptive analyses of baseline characteristics, radiologic parameters, comorbidities, and outcome measures were completed.

RESULTS

Twenty elderly patients (mean age of 81.0 years) with multiple comorbidities underwent 28 MMA embolization+SEPS procedures as primary treatment for cSDH. Mean cSDH thickness was 1.8cm±0.6 cm with 7.3±3.9 mm midline shift. All patients tolerated the procedure well. 1/20 (5.0%) patients died within 30 days of the procedure. A majority of patients were discharged to home (12/20; 60.0%). There was an average of 3.6-month follow-up and one patient (5.0%) developed recurrence in the follow-up period requiring further intervention.

CONCLUSIONS

In select elderly patients with high perioperative risk factors, primary treatment of cSDH using awake transradial MMA embolization+SEPS placement is a minimally invasive, feasible, and safe option. Further comparative studies are warranted to evaluate efficacy of the treatment.

Non-surgical patient characteristics best predict outcome after 6 months in patients surgically treated for chronic subdural haematoma

BACKGROUND

Chronic subdural haematoma (CSDH) is one of the most common conditions encountered in neurosurgical practice. After surgery, the patients often improve dramatically; but their long-term outcome is more uncertain. The purpose of this study was to investigate predictors of outcome 6 months after surgery.

METHODS

Retrospective data were collected on patients in Orebro County, Sweden, who had undergone surgery for CSDH at the Orebro University Hospital between 2013 and 2019. The outcomes were defined as favourable or unfavourable in terms of the modified Rankin Scale (mRS). A favourable outcome was defined as either mRS 0-2 or an unchanged mRS score in patients scoring 3-5 before surgery. From the variables in the data collected, a multiple logistic regression model was constructed.

RESULTS

The study comprised 180 patients, of whom 134 (74.4%) were male. Median age was 79.2 years (IQR 71.7-85.5), and 129 (71.7%) patients had a favourable outcome at 6 months. In the group with an unfavourable outcome, 18 (10%) had died and 33 (18.3%) had either lost their independence in daily living or become somewhat less independent. The final multiple logistic regression model consisted of pre-surgery variables only: age (OR 0.92, 95% CI 0.87-0.97), CRP (OR 0.96, 95% CI 0.94-0.99), GCS > 13 (OR 3.66, 95% CI 1.09-12.3), Hb (OR 1.03, 95% CI 1.00-1.05), and ASA score < 3 (OR 2.58, 95% CI 0.98-6.79). The whole model had an AUC of 0.88.

CONCLUSION

CSDH requiring surgery is associated with high morbidity and mortality at 6 months after surgery. Age, CRP, GCS, Hb and ASA score on admission for surgery are the variables that best predicts outcome. This knowledge can help to identify the patients at greatest risk for an unfavourable outcome, who may need additional support from the health care system.

UNSTRUCTURED ABSTRACT

Chronic subdural haematoma (CSDH) is one of the most common conditions encountered in neurosurgical practice. After surgery, the patients often improve dramatically; but their long-term outcome is more uncertain. The purpose of this study was to investigate predictors of outcome, in terms of the modified Rankin Scale (mRS), 6 months after surgery. The study comprised 180 patients, of whom 134 (74.4%) were male. Median age was 79.2 years (IQR 71.7-85.5), and 129 (71.7%) patients had a favourable outcome at 6 months. In the group with an unfavourable outcome, 18 (10%) had died and 33 (18.3%) had either lost their independence in daily living or become somewhat less independent. The final multiple logistic regression model consisted of pre-surgery variables only: age (OR 0.92, 95% CI 0.87-0.97), CRP (OR 0.96, 95% CI 0.94-0.99), GCS > 13 (OR 3.66, 95% CI 1.09-12.3), Hb (OR 1.03, 95% CI 1.00-1.05), and ASA score < 3 (OR 2.58, 95% CI 0.98-6.79). The whole model had an AUC of 0.88. In conclusion, CSDH requiring surgery is associated with high morbidity and mortality at 6 months after surgery. Age, CRP, GCS, Hb and ASA score on admission for surgery are the variables that best predicts outcome. This knowledge can help to identify the patients at greatest risk for an unfavourable outcome, who may need additional support from the health care system.

Clinical Characteristics and Surgical Outcomes of Super-Elderly Patients with Chronic Subdural Hematoma

OBJECTIVE

Surgical intervention for chronic subdural hematoma (CSDH) in the extremely aged population remains a difficult challenge. This study aims to investigate the clinical characteristics and surgical outcomes after twist drill craniotomy (TDC) of CSDH in super-elderly (≥80 years) patients.

METHODS

A retrospective analysis of super-elderly patients with CSDH who underwent TDC treatment in our hospital between January 2013 and December 2021 was performed. Their clinical characteristics and surgical outcomes were compared with those of relatively younger patients (60-79 years). Factors that may affect functional outcomes were also investigated.

RESULTS

Fifty-nine super-elderly patients and 133 patients aged 60-79 years were included. The preoperative hematoma volume of the super-elderly patients was significantly larger than that of the 60-79 years group, whereas fewer super-elderly patients had headaches compared with the relatively younger counterparts. After surgical treatment using the TDC procedure, the incidence of complication and the hematoma recurrence rate were similar between the 2 groups. Moreover, according to the Markwalder score of the follow-up at 6 months after operation, the prognosis of the super-elderly group was not poorer than that of the patients of 60-79 years (P = 0.662). Preoperative dysfunction of coagulation (odds ratio, 28.421; 95% confidence interval, 1.185-681.677; P = 0.039) was an independent risk factor significantly related to unfavorable outcomes of super-elderly patients with CSDH.

CONCLUSIONS

Advanced age per se does not seem to be a contraindication for the operative intervention of CSDH. Surgical treatment using the TDC procedure can still provide considerable benefits for super-elderly patients with CSDH.

Time to medical fitness for discharge following surgical evacuation of chronic subdural haematoma with general or regional anaesthesia: a prospective randomised trial

General or regional anaesthesia can be used for chronic subdural haematoma evacuation, but no study has compared these types of anaesthesia in terms of peri-operative outcomes. This single-centre, prospective, randomised study included adult patients (age ≥ 18 years) undergoing surgical chronic subdural haematoma evacuation. Patients were randomly allocated to general (target-controlled total intravenous anaesthesia with propofol and remifentanil) or regional anaesthesia (bilateral scalp block with remifentanil sedation if required). The primary outcome measure was duration of hospital stay, based on the day patients were judged by an investigator blinded from the allocation group to be medically fit for discharge. Secondary outcomes included: rate of regional anaesthesia failure; rate of intra-operative and postoperative adverse events at 24 hours; and pain scores at 24 hours. Data from 60 patients were analysed (30 general anaesthesia and 30 regional anaesthesia). Median (IQR [range]) time until patients were judged medically fit for discharge was 3 (3-3 [2-10]) days and 3 (2-5 [2-15]) days for general and regional anaesthesia, respectively (p = 0.700). Regional anaesthesia failed in two patients. There were more intra-operative adverse events in patients who received general anaesthesia (25 vs. 11, respectively; p = 0.001). The occurrence of postoperative adverse events was similar for general and regional anaesthesia (16 vs. 13 patients, respectively; p = 0.605). In patients requiring chronic subdural haematoma evacuation, general and regional anaesthesia are comparable in terms of duration of time until medically fit for discharge and occurrence of postoperative complications. The rate of intra-operative adverse events (mainly arterial hypotension) is greater with general anaesthesia.

Outcomes of patients with nonepileptic transient neurologic symptoms after subdural hematoma evacuation

BACKGROUND

Patients undergoing a subdural hematoma (SDH) evacuation can experience transient neurological symptoms (TNS) postoperatively. Electroencephalography (EEG) is used to rule out seizures. We aim to characterize patients with TNS and negative epileptiform activity on EEG and compare them to those with positive epileptiform EEG findings.

METHODS

We performed a retrospective study of adult patients who underwent EEG for evaluation of TNS after undergoing SDH evacuation. Patients were stratified based on SDH type (acute and non-acute) and whether or not their EEG demonstrated positive epileptiform activity. A multivariate analysis was performed to identify predictors of negative EEG findings.

RESULTS

One hundred twenty-nine SDH patients were included (45 (34.9%) acute; 84 (65.1%) non-acute). Overall, 45 (24 acute and 21 non-acute SDH patients) had positive epileptiform EEG findings, and 84 (21 acute and 63 non-acute SDH patients) had a negative EEG. Acute and non-acute SDH patients with positive EEG findings were more likely to suffer from greater than five episodes of TNS, impaired awareness, and motor symptoms, while the negative EEG group was more likely to suffer from negative symptoms. Non-acute SDH patients with positive EEG had longer mean ICU stays (14.6 vs. 7.2; p = 0.005). Both acute and non-acute SDH-positive EEG patients had worse disposition upon discharge (p < 0.05), worse modified Rankin score at discharge (p < 0.05), and 3-month follow-up (p < 0.05) and were more likely to be discharged on more than one antiepileptic drug (p < 0.001).

CONCLUSION

Postoperative acute and non-acute SDH patients with TNS and negative EEG results are likely to have a favorable clinical picture. This distinction is therapeutically and prognostically important as these patients may not respond to typical antiepileptic drugs and they have better functional outcomes.

Middle meningeal artery embolization with subdural evacuating port system for primary management of chronic subdural hematomas

Optimal treatment for chronic subdural hematomas remains controversial and perioperative risks and comorbidities may affect management strategies. Minimally invasive procedures are emerging as alternatives to the standard operative treatments. We evaluate our experience with middle meningeal artery (MMA) embolization combined with Subdural Evacuating Port System (SEPS) placement as a first-line treatment for patients with cSDH. A single institution retrospective review was performed of all patients undergoing intervention. Patients were stratified by treatment with MMA embolization and SEPS placement, MMA embolization and surgery, SEPS placement only, and surgery only for cSDH from 2017 to 2020, and cohorts were compared against each other. Patients treated with MMA/SEPS were more likely to be older, be on anticoagulation, have significant comorbidities, have shorter length of stay, and less likely to have symptomatic recurrence compared to SEPS only cohort. Thus, MMA/SEPS appears to be a safe and equally effective minimally invasive treatment for cSDH patients with significant comorbidities who are poor surgical candidates.