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Mignucci-Jiménez G, Matos-Cruz AJ, Koskay G, Hanalioglu S, Gonzalez-Romo NI, Xu Y, Kovacs MS, Preul MC, Feliciano-Valls CE. Modified Puerto Rico Recurrence Scale for chronic subdural hematomas: augmenting the grading scale with postoperative pneumocephalus volume. Acta Neurochir (Wien) 2023; 165:3229-3238. [PMID: 37648846 DOI: 10.1007/s00701-023-05737-w] [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: 11/28/2022] [Accepted: 06/30/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND Chronic subdural hematomas (CSDHs) are common in the elderly, with a relatively high rate of recurrence after initial surgical intervention. Our research team previously created a predictive grading system, the Puerto Rico Recurrence Scale (PRRS), to identify patients at high risk of CSDH recurrence. In this study, we introduce a modification of the (mPRRS) that includes pneumocephalus volume, which has been independently associated with recurrence. METHODS A single-center Puerto Rican population-based retrospective study was performed to analyze data for patients treated for CSDH at 1 institution between July 1, 2017, and December 31, 2019. Univariate and multivariate analyses were used to create a grading scale predictive of recurrence. Retrospective validation was conducted for the cohort. RESULTS Of 108 patients included in the study, 42 had recurrence, and 66 had nonrecurrence. Postoperative subdural space, postoperative midline shift, and pneumocephalus volume were all higher with recurrence (P = 0.002, P = 0.009, and P < 0.001, respectively). Multivariate analysis was used to create a 6-point grading scale comprising 3 variables (pneumocephalus volume [< 10, 10-20, 21-30, and > 30 cm3], postoperative midline shift [< 0.4, 0.41-1.0, and > 1.0 cm], and laterality [unilateral and bilateral]). Recurrence rates progressively increased in low-risk to high-risk groups (2/18 [11%] vs 21/34 [62%]; P < 0.003). CONCLUSION The mPRRS incorporating pneumocephalus measurement improves CSDH recurrence prediction. The mPRRS indicated that patients with higher scores have a greater risk of recurrence and emphasized the importance of measuring postoperative variables for prediction. The mPRRS grading scale for CSDHs may be applicable not only to the Puerto Rican population but also to the general population.
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Affiliation(s)
- Giancarlo Mignucci-Jiménez
- Neurosurgery Section, Department of Surgery, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico
- The Loyal and Edith Davis Neurosurgical Research Laboratory, C/O Neuroscience Publications, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA
| | - Alejandro J Matos-Cruz
- Neurosurgery Section, Department of Surgery, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico
- Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Grant Koskay
- The Loyal and Edith Davis Neurosurgical Research Laboratory, C/O Neuroscience Publications, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA
| | - Sahin Hanalioglu
- The Loyal and Edith Davis Neurosurgical Research Laboratory, C/O Neuroscience Publications, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA
| | - Nicolas I Gonzalez-Romo
- The Loyal and Edith Davis Neurosurgical Research Laboratory, C/O Neuroscience Publications, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA
| | - Yuan Xu
- The Loyal and Edith Davis Neurosurgical Research Laboratory, C/O Neuroscience Publications, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA
| | - Melissa S Kovacs
- The Loyal and Edith Davis Neurosurgical Research Laboratory, C/O Neuroscience Publications, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA
| | - Mark C Preul
- The Loyal and Edith Davis Neurosurgical Research Laboratory, C/O Neuroscience Publications, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA.
| | - Caleb E Feliciano-Valls
- Neurosurgery Section, Department of Surgery, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico
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Henry J, Amoo M, Crockett MT, Javadpour M. Middle Meningeal Artery Embolization for Chronic Subdural Hematoma-A New Treatment Paradigm? World Neurosurg 2023; 172:3-4. [PMID: 36682525 DOI: 10.1016/j.wneu.2023.01.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Jack Henry
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland; Department of Neurosurgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Michael Amoo
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland; Department of Neurosurgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Matthew T Crockett
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland; Department of Neuroradiology, Beaumont Hospital, Dublin, Ireland
| | - Mohsen Javadpour
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland; Department of Neurosurgery, Royal College of Surgeons in Ireland, Dublin, Ireland; Department of Academic Neurology, Trinity College Dublin, Dublin, Ireland
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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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Henry J, Amoo M, Kissner M, Deane T, Zilani G, Crockett MT, Javadpour M. Management of Chronic Subdural Hematoma: A Systematic Review and Component Network Meta-analysis of 455 Studies With 103 645 Cases. Neurosurgery 2022; 91:842-855. [PMID: 36170165 DOI: 10.1227/neu.0000000000002144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 07/14/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Chronic subdural hematoma (CSDH) is a common neurosurgical condition with a high risk of recurrence after treatment. OBJECTIVE To assess and compare the risk of recurrence, morbidity, and mortality across various treatments for CSDH. METHODS A systematic review and meta-analysis was performed. PubMed/MEDLINE, EMBASE, SCOPUS, and Web of Science were searched from January 01, 2000, to July 07, 2021. The primary outcome was recurrence, and secondary outcomes were morbidity and mortality. Component network meta-analyses (CNMAs) were performed for surgical and medical treatments, assessing recurrence and morbidity. Incremental risk ratios (iRRs) with 95% CIs were estimated for each component. RESULTS In total, 12 526 citations were identified, and 455 studies with 103 645 cases were included. Recurrence occurred in 11 491/93 525 (10.8%, 95% CI 10.2-11.5, 418 studies) cases after surgery. The use of a postoperative drain (iRR 0.53, 95% CI 0.44-0.63) and middle meningeal artery embolization (iRR 0.19, 95% CI 0.05-0.83) reduced recurrence in the surgical CNMA. In the pharmacological CNMA, corticosteroids (iRR 0.47, 95% CI 0.36-0.61) and surgical intervention (iRR 0.11, 95% CI 0.07-0.15) were associated with lower risk. Corticosteroids were associated with increased morbidity (iRR 1.34, 95% CI 1.05-1.70). The risk of morbidity was equivalent across surgical treatments. CONCLUSION Recurrence after evacuation occurs in approximately 10% of cSDHs, and the various surgical interventions are approximately equivalent. Corticosteroids are associated with reduced recurrence but also increased morbidity. Drains reduce the risk of recurrence, but the position of drain (subdural vs subgaleal) did not influence recurrence. Middle meningeal artery embolization is a promising treatment warranting further evaluation in randomized trials.
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Affiliation(s)
- Jack Henry
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland
| | - Michael Amoo
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland.,Department of Neurosurgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Malia Kissner
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Thomas Deane
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Gulam Zilani
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland
| | - Matthew T Crockett
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland.,Department of Neuroradiology, Beaumont Hospital, Dublin, Ireland
| | - Mohsen Javadpour
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland.,Department of Neurosurgery, Royal College of Surgeons in Ireland, Dublin, Ireland.,Department of Academic Neurology, Trinity College Dublin, Dublin, Ireland
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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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