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Adegboyega G, Gillespie CS, Watson M, Lee KS, Brannigan J, Mazzoleni A, Goacher E, Mantle O, Omar V, Gamage G, Touzet AY, Mowforth O, Stubbs DJ, Davies BM, Hutchinson PJ. Seniority of Surgeon in Chronic Subdural Hematoma Recurrence: A Systematic Review and Meta-analysis. World Neurosurg 2024; 189:381-386.e1. [PMID: 38901476 DOI: 10.1016/j.wneu.2024.06.071] [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: 04/03/2024] [Revised: 06/13/2024] [Accepted: 06/14/2024] [Indexed: 06/22/2024]
Abstract
Chronic subdural hematoma (CSDH) is increasingly common, particularly in the older and multimorbid population. Surgical proficiency in management is required in the early years of U.K. neurosurgical training with most cases performed by nonconsultant-grade surgeons. The aim of this systematic review was to examine the effect of surgeon seniority on recurrence for patients with CSDH. Full-text articles comparing surgical treatment for CSDH with a "senior" (consultant/attending level) or "junior" (resident/registrar or similar) lead surgeon were identified. MEDLine and EMBASE databases were searched. The primary outcome of this study was recurrence. Secondary outcomes included postoperative complications and mortality rate. A random effects meta-analysis was performed. The risk of bias was assessed using the National Institute of Health risk of bias toolkit. Five studies were included in the final analysis (n = 941 total patients). Individually, no study identified a significant difference in recurrence rate and postoperative complications between senior and junior neurosurgeons. On meta-analysis, junior-led evacuations had lower recurrence rates on pooled univariable analysis (12.0% vs. 17.9% [odds ratio 0.48, 95% confidence interval 0.29-0.78, I2 = 0%]) (3 studies). Seniority of surgeon was not associated with increased rates of recurrence patients undergoing CSDH surgery. Complexity of operation may be a confounding factor in observed lower recurrence rates with more junior operators.
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Affiliation(s)
- Gideon Adegboyega
- Department of Clinical Neurosciences, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Conor S Gillespie
- Department of Clinical Neurosciences, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Matthew Watson
- Clinical School of Medicine, University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Keng Siang Lee
- Department of Neurosurgery, King's College Hospital, London, United Kingdom
| | - Jamie Brannigan
- Department of Clinical Neurosciences, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Adele Mazzoleni
- Barts and The London School of Medicine, Queen Mary University of London, London, United Kingdom
| | - Edward Goacher
- Sheffield University Teaching Hospitals NHS Trust, Sheffield, United Kingdom
| | - Orla Mantle
- King's College Medical School, London, United Kingdom
| | - Vian Omar
- University of Buckingham Medical School, Buckingham, United Kingdom
| | - Githmi Gamage
- Royal College of Surgeons of Ireland, Dublin, Ireland
| | - Alvaro Yanez Touzet
- School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Oliver Mowforth
- Department of Clinical Neurosciences, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Daniel J Stubbs
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Benjamin M Davies
- Department of Clinical Neurosciences, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom.
| | - Peter J Hutchinson
- Department of Clinical Neurosciences, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
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Serag I, Abdelhady M, Awad AA, Wageeh A, Shaboub A, Elhalag RH, Aljabali A, Abouzid M. Postoperative elevated bed header position versus supine in the management of chronic subdural hematoma: a systematic review and meta-analysis. Acta Neurol Belg 2024; 124:1177-1187. [PMID: 38802719 PMCID: PMC11266250 DOI: 10.1007/s13760-024-02571-4] [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: 02/25/2024] [Accepted: 05/06/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND Chronic subdural hematoma (CSDH) is a prevalent type of intracranial hemorrhage. Surgical interventions, such as Twist Drill Craniostomy and Burr Hole Craniostomy, are employed for its treatment. However, limited information exists regarding the impact of postoperative head position (supine vs. elevated) on clinical outcomes. We aim to assess whether patients' head position after surgery influences their prognosis. METHOD We conducted a PRISMA-compliant systematic review and meta-analysis. Our search encompassed PubMed, Cochrane CENTRAL, Scopus, Web of Science, and Embase databases to identify relevant published studies. Data were meticulously extracted, pooled using a fixed model, and reported as risk ratios (RR) with 95% confidence intervals (CI). Statistical analysis was performed using R and Stata MP v.17. RESULTS Five studies involving 284 patients were included in our meta-analysis. We focused on three primary clinical outcomes, comparing the supine and elevated header positions. Notably, there was no statistically significant difference between the supine and elevated positions in terms of recurrence rate (RR 0.77, 95% CI [0.44, 1.37]), second intervention for recurrence (RR 1.07, 95% CI [0.42, 2.78]) and postoperative complications (RR 1.16, 95% CI [0.70, 1.92]). CONCLUSION Current studies have proved no difference between supine and elevated bed header positions regarding recurrence rate, second intervention for recurrence, and postoperative complications. Future RCTs with long-term follow-ups are recommended.
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Affiliation(s)
- Ibrahim Serag
- Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | | | | | - Ahmed Wageeh
- Faculty of Medicine, Menoufia University, Menoufia, Egypt
| | - Ahmed Shaboub
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Rowan H Elhalag
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Ahmed Aljabali
- Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Mohamed Abouzid
- Department of Physical Pharmacy and Pharmacokinetics, Faculty of Pharmacy, Poznan University of Medical Sciences, Rokietnicka 3 St, 60-806, Poznan, Poland.
- Doctoral School, Poznan University of Medical Sciences, 60-812, Poznan, Poland.
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Hounkpatin S, Stierer M, Frechon P, Rault F, Kelani A, Emery E, Gaberel T, Leclerc A. Comparative analysis of surgical techniques in the management of chronic subdural hematomas and risk factors for poor outcomes. Neurosurg Rev 2024; 47:254. [PMID: 38829539 DOI: 10.1007/s10143-024-02493-y] [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: 11/19/2023] [Revised: 04/29/2024] [Accepted: 05/25/2024] [Indexed: 06/05/2024]
Abstract
Chronic subdural hematomas (CSDH) are increasingly prevalent, especially among the elderly. Surgical intervention is essential in most cases. However, the choice of surgical technique, either craniotomy or burr-hole opening, remains a subject of debate. Additionally, the risk factors for poor long-term outcomes following surgical treatment remain poorly described. This article presents a 10-year retrospective cohort study conducted at a single center that aimed to compare the outcomes of two common surgical techniques for CSDH evacuation: burr hole opening and minicraniotomy. The study also identified risk factors associated with poor long-term outcome, which was defined as an mRS score ≥ 3 at 6 months. This study included 582 adult patients who were surgically treated for unilateral CSDH. Burr-hole opening was performed in 43% of the patients, while minicraniotomy was performed in 57%. Recurrence was observed in 10% of the cases and postoperative complications in 13%. The rates of recurrence, postoperative complications, death and poor long-term outcome did not differ significantly between the two surgical approaches. Multivariate analysis identified postoperative general complications, recurrence, and preoperative mRS score ≥ 3 as independent risk factors for poor outcomes at 6 months. Recurrence contribute to a poorer prognosis in CSDH. Nevertheless, use burr hole or minicraniotomy for the management of CSDH showed a similar recurrence rate and no significant differences in post-operative outcomes. This underlines the need for a thorough assessment of patients with CSHD and the importance of avoiding their occurrence, by promoting early mobilization of patients. Future research is necessary to mitigate the risk of recurrence, regardless of the surgical technique employed.
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Affiliation(s)
- Stachys Hounkpatin
- Caen University Hospital, Department of Neurosurgery, Caen, France
- Niamey University Hospital, Department of Neurosurgery, Niamey, Niger
- Caen Normandy University, Caen, France
| | | | - Paul Frechon
- Caen University Hospital, Department of Neurosurgery, Caen, France
- Caen Normandy University, Caen, France
| | - Frederick Rault
- Caen University Hospital, Department of Neurosurgery, Caen, France
| | - Aminath Kelani
- Niamey University Hospital, Department of Neurosurgery, Niamey, Niger
- Abdou Moumouni University, Niamey, Niger
| | - Evelyne Emery
- Caen University Hospital, Department of Neurosurgery, Caen, France
- Caen Normandie University, INSERM, U1237, PhIND Physiopathology and Imaging of Neurological Disorders, Institut Blood and Brain @ Caen-Normandie, GIP Cyceron, Caen, France
| | - Thomas Gaberel
- Caen University Hospital, Department of Neurosurgery, Caen, France
- Caen Normandie University, INSERM, U1237, PhIND Physiopathology and Imaging of Neurological Disorders, Institut Blood and Brain @ Caen-Normandie, GIP Cyceron, Caen, France
| | - Arthur Leclerc
- Caen University Hospital, Department of Neurosurgery, Caen, France.
- Caen Normandie University, ISTCT UMR6030, GIP Cyceron, Caen, France.
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Staartjes VE, Spinello A, Schwendinger N, Germans MR, Serra C, Regli L. Safety and Effectiveness of an Enhanced Recovery Protocol in Patients Undergoing Burr Hole Evacuation for Chronic Subdural Hematoma. Neurosurgery 2024; 95:00006123-990000000-01042. [PMID: 38323829 PMCID: PMC11155564 DOI: 10.1227/neu.0000000000002849] [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: 10/02/2023] [Accepted: 12/19/2023] [Indexed: 02/08/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Enhanced recovery programs may be especially useful in patients with chronic subdural hematoma or hygroma (cSDH), who frequently exhibit frailty and multimorbidity. We aim to evaluate the real-world safety and effectiveness of an enhanced recovery protocol in this population. METHODS From a prospective registry, burr hole evacuations for cSDH carried out under the protocol (including early thromboprophylaxis, no flat bed rest, early mobilization without drain clamping, and early resumption of antithrombotic medication) were extracted, along with those procedures carried out within the past year before protocol change. Propensity score-based matching was carried out. A range of clinical and imaging outcomes were analyzed, including modified Rankin Scale as effectiveness and Clavien-Dindo adverse event grading as safety primary end points. RESULTS Per group, 91 procedures were analyzed. At discharge, there was no significant difference in the modified Rankin Scale among the standard and enhanced recovery groups (1 [1; 2] vs 1 [1; 3], P = .552), or in Clavien-Dindo adverse event grading classifications of adverse events (P = .282) or occurrence of any adverse events (15.4% vs 20.9%, P = .442). There were no significant differences in time to drain removal (2.00 [2.00; 2.00] vs 2.00 [1.25; 2.00] days, P = .058), time from procedure to discharge (4.0 [3.0; 6.0] vs 4.0 [3.0; 6.0] days, P = .201), or total hospital length of stay (6.0 [5.0; 9.0] vs 5.0 [4.0; 8.0] days, P = .113). All-cause mortality was similar in both groups (8.8% vs 4.4%, P = .289), as was discharge disposition (P = .192). Other clinical and imaging outcomes were similar too (all P > .05). CONCLUSION In a matched cohort study comparing perioperative standard of care with a novel enhanced recovery protocol focusing on evidence-based drainage, mobilization, and thromboprophylaxis regimens as well as changes to the standardized reuptake of oral anticoagulants and antiaggregants, no differences in safety or effectiveness were observed after burr hole evacuation of cSDH.
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Affiliation(s)
- Victor E. Staartjes
- Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Antonio Spinello
- Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Nina Schwendinger
- Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Menno R. Germans
- Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Carlo Serra
- Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Luca Regli
- Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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Wagner A, Wostrack M, Hartz F, Heim J, Hameister E, Hildebrandt M, Meyer B, Winter C. The role of extended coagulation screening in adult cranial neurosurgery. BRAIN & SPINE 2023; 3:101756. [PMID: 37383462 PMCID: PMC10293229 DOI: 10.1016/j.bas.2023.101756] [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: 11/03/2022] [Revised: 04/23/2023] [Accepted: 05/10/2023] [Indexed: 06/30/2023]
Abstract
Introduction Postoperative hemorrhage after adult cranial neurosurgery is a serious complication with substantial morbidity and mortality. Research question We investigated if an extended preoperative screening and an early treatment of previously undetected coagulopathies may decrease the risk of postoperative hemorrhage. Methods A prospective study cohort of patients undergoing elective cranial surgery and receiving the extended coagulatory work-up were compared to a propensity matched historical control cohort. The extended work-up included a standardized questionnaire on the patient's bleeding history as well as coagulatory tests of Factor XIII, von-Willebrand-Factor and PFA-100®. Deficiencies were substituted perioperatively. The primary outcome was determined as the surgical revision rate due to postoperative hemorrhage. Results The study cohort and the control cohort included 197 cases each, without any significant difference in the preoperative intake of anticoagulant medication (p = .546). Most common interventions were resections of malignant tumors (41%), benign tumors (27%) and neurovascular surgeries (9%) in both cohorts. Imaging revealed postoperative hemorrhage in 7 cases (3.6%) in the study cohort and 18 cases (9.1%) in the control cohort (p = .023). Of these, revision surgeries were significantly more common in the control cohort with 14 cases (9.1%) compared to 5 cases (2.5%) in the study cohort (p = .034). Differences in mean intraoperative blood loss were not significant with 528 ml in the study cohort and 486 ml in the control cohort (p = .376). Conclusion Preoperative extended coagulatory screening may allow for revealing previously undiagnosed coagulopathies with subsequent preoperative substitution and thereby reduction of risk for postoperative hemorrhage in adult cranial neurosurgery.
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Affiliation(s)
- Arthur Wagner
- Department of Neurosurgery, Technical University Munich School of Medicine, Munich, Germany
| | - Maria Wostrack
- Department of Neurosurgery, Technical University Munich School of Medicine, Munich, Germany
| | - Frederik Hartz
- Department of Neurosurgery, Technical University Munich School of Medicine, Munich, Germany
| | - Johannes Heim
- Department of Neurosurgery, Technical University Munich School of Medicine, Munich, Germany
| | - Erik Hameister
- Institute of Clinical Chemistry and Pathobiochemistry, Technical University Munich School of Medicine, Munich, Germany
| | - Martin Hildebrandt
- Institute of Clinical Chemistry and Pathobiochemistry, Technical University Munich School of Medicine, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Technical University Munich School of Medicine, Munich, Germany
| | - Christof Winter
- Institute of Clinical Chemistry and Pathobiochemistry, Technical University Munich School of Medicine, Munich, Germany
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6
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Ebel F, Greuter L, Lutz K, Häni L, Fandino J, Guzman R, Mariani L, Beck J, Raabe A, Z’Graggen WJ, Schucht P, Soleman J. The Role of Active or Passive Drainage after Evacuation of Chronic Subdural Hematoma: An Analysis of Two Randomized Controlled Trials (cSDH-Drain-Trial and TOSCAN Trial). Diagnostics (Basel) 2022; 12:3045. [PMID: 36553053 PMCID: PMC9777194 DOI: 10.3390/diagnostics12123045] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 11/26/2022] [Accepted: 11/29/2022] [Indexed: 12/09/2022] Open
Abstract
The evacuation of a chronic subdural hematoma (cSDH) is one of the most common procedures in neurosurgery. The aim of this study was to assess the influence of drainage suction in the surgical treatment of cSDH on the recurrence rate. Post hoc analysis was conducted on two randomized controlled trials (cSDH-Drain-Trial and TOSCAN trial) stratifying a total of 581 patients into active or passive drain type. Of the 581 patients, 359 (61.8%) and 220 (37.9%) were stratified into the active and passive drainage groups, respectively. The reoperation rate following postoperative recurrence was 23.1% and 14.1% in the active and passive drainage groups, respectively (p < 0.011). After propensity score matching, the differences in recurrence rate remained significant (26.6% versus 15.6%, p = 0.012). However, the functional outcome (mRS) at 6−12 months did not differ significantly (median [IQR]) between the 2 groups (passive drainage group 0.00 [0.00, 2.00], active drainage group 1.00 [0.00, 2.00], p = 0.431). Mortality was comparable between the groups (passive drainage group 12 (5.5%), active drainage group 20 (5.6%), p = 0.968). In the univariate analysis, active drainage, short (<48 h) duration of drainage, and early (<48 h) postoperative mobilization were significantly associated with a higher recurrence rate. However, the multivariate logistic regression model could not confirm that any of these parameters were significantly associated with recurrence. Our post hoc analysis proposes that using a passive instead of an active drain might be associated with a reduced recurrence rate after evacuation of a cSDH. We suggest gathering further evidence by means of a randomized controlled trial.
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Affiliation(s)
- Florian Ebel
- Department of Neurosurgery, University Hospital of Basel, 4031 Basel, Switzerland
- Department of Neurosurgery, Inselspital, University Hospital of Bern, 3010 Bern, Switzerland
| | - Ladina Greuter
- Department of Neurosurgery, University Hospital of Basel, 4031 Basel, Switzerland
| | - Katharina Lutz
- Department of Neurosurgery, Inselspital, University Hospital of Bern, 3010 Bern, Switzerland
| | - Levin Häni
- Department of Neurosurgery, Inselspital, University Hospital of Bern, 3010 Bern, Switzerland
| | - Javier Fandino
- Department of Neurosurgery, Klinik Hirslanden, 8032 Zürich, Switzerland
| | - Raphael Guzman
- Department of Neurosurgery, University Hospital of Basel, 4031 Basel, Switzerland
- Faculty of Medicine, University of Basel, 4031 Basel, Switzerland
| | - Luigi Mariani
- Department of Neurosurgery, University Hospital of Basel, 4031 Basel, Switzerland
- Faculty of Medicine, University of Basel, 4031 Basel, Switzerland
| | - Jürgen Beck
- Department of Neurosurgery, Inselspital, University Hospital of Bern, 3010 Bern, Switzerland
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, University Hospital of Bern, 3010 Bern, Switzerland
| | - Werner J. Z’Graggen
- Department of Neurosurgery, Inselspital, University Hospital of Bern, 3010 Bern, Switzerland
- Department of Neurology, Inselspital, University Hospital of Bern, 3010 Bern, Switzerland
| | - Philippe Schucht
- Department of Neurosurgery, Inselspital, University Hospital of Bern, 3010 Bern, Switzerland
| | - Jehuda Soleman
- Department of Neurosurgery, University Hospital of Basel, 4031 Basel, Switzerland
- Faculty of Medicine, University of Basel, 4031 Basel, Switzerland
- Clinical Trial Unit, University Hospital of Basel, 4031 Basel, Switzerland
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7
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Zhu F, Wang H, Li W, Han S, Yuan J, Zhang C, Li Z, Fan G, Liu X, Nie M, Bie L. Factors correlated with the postoperative recurrence of chronic subdural hematoma: An umbrella study of systematic reviews and meta-analyses. EClinicalMedicine 2022; 43:101234. [PMID: 34988412 PMCID: PMC8703229 DOI: 10.1016/j.eclinm.2021.101234] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 11/08/2021] [Accepted: 11/24/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Chronic subdural hematoma (CSDH) is a common neurological disease, and the surgical evacuation of subdural collection remains the primary treatment approach for symptomatic patients. Postoperative recurrence is a serious complication, and several factors are correlated with postoperative recurrence. METHODS We searched Embase, Web of Science, PubMed, and Cochrane Library from their establishment to September 2020. Reports on randomized, prospective, retrospective, and overall observational studies on the management of surgical patients with CSDH were searched, and an independent reviewer performed research quality assessment. Factors that affect the postoperative recurrence of CSDH were extracted: social demographics, drugs (as the main or auxiliary treatment), surgical management, imaging, and other risk factors. We evaluated the recurrence rate of each risk factor. A random effect model was used to perform a meta-analysis, and each risk factor affecting the postoperative recurrence of CSDH was then evaluated and graded. FINDINGS In total, 402 studies were included in this analysis and 32 potential risk factors were evaluated. Among these, 21 were significantly associated with the postoperative recurrence of CSDH. Three risk factors (male, bilateral hematoma, and no drainage) had convincing evidence. The classification of evidence can help clinicians identify significant risk factors for the postoperative recurrence of CSDH. INTERPRETATION Only few associations were supported by high-quality evidence. Factors with high-quality evidence may be important for treating and preventing CSDH recurrence. Our results can be used as a basis for improving clinical treatment strategies and designing preventive methods. FUNDING No funding was received.
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Affiliation(s)
- Fulei Zhu
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Haifeng Wang
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Wenchen Li
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Shuai Han
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Jiangyuan Yuan
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Chunyun Zhang
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Zean Li
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Guangyan Fan
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Xuanhui Liu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Meng Nie
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Li Bie
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
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Tamura R, Sato M, Yoshida K, Toda M. History and current progress of chronic subdural hematoma. J Neurol Sci 2021; 429:118066. [PMID: 34488045 DOI: 10.1016/j.jns.2021.118066] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Revised: 08/25/2021] [Accepted: 08/31/2021] [Indexed: 11/18/2022]
Abstract
Chronic subdural hematoma (CSDH) is characterized by an encapsulated collection of old blood. Although CSDH has become the most frequent pathologic entity in daily neurosurgical practice, there are some unresolved research questions. In particular, the causes and recurrent risk factors of CSDH remain as an object of debate. The split of the dural border layer forms a few tiers of dural border cells over the arachnoid layer. Tissue plasminogen activator plays an important role as a key factor of defective coagulation. Historically, CSDH has often been treated via burr hole craniostomy using a closed drainage system. Several different operative strategies and peri-operative strategies such as the addition of burr holes, addition of cavity irrigation, position of drain, or postural position, have been described previously. Although the direction of the drainage tube, residual air, low intensity of T1-weighted images on MRI, and niveau formation have been reported as risk factors for recurrence, antiplatelet or anticoagulant drug use has not yet been verified as a risk factor. Recently, pharmaceutical strategies, including atorvastatin, significantly improved the neurological function in CSDH patients. Many case series, without randomization, have been reported; and given its promising result, several randomized clinical trials using pharmaceutical as well as operative and perioperative strategies were initiated to obtain sufficient data. In contrast, relatively fewer basic studies have achieved clinical applications in CSDH, although it is one of the most common clinical entities. Further scientific basic research may be essential for achieving a novel treatment strategy for CSDH.
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Affiliation(s)
- Ryota Tamura
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan; Department of Neurosurgery, Kawasaki Municipal Hospital, Shinkawadori, Kawasaki-ku, Kanagawa 210-0013, Japan
| | - Mizuto Sato
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Kazunari Yoshida
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Masahiro Toda
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan.
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Makler V, D'Agostino E, Guerin SJ, Jaleel N. Burr hole craniostomy with novel use of subdural drain for evacuation of chronic subdural hematoma: Case series, literature review, and technical note. INTERDISCIPLINARY NEUROSURGERY 2019. [DOI: 10.1016/j.inat.2019.100501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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10
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Májovský M, Netuka D, Beneš V, Kučera P. Burr-Hole Evacuation of Chronic Subdural Hematoma: Biophysically and Evidence-Based Technique Improvement. J Neurosci Rural Pract 2019; 10:113-118. [PMID: 30765981 PMCID: PMC6337972 DOI: 10.4103/jnrp.jnrp_167_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Chronic subdural hematoma (CSDH) is one of the most common neurosurgical conditions. Despite ongoing efforts, recurrence and reoperation rates after surgical treatment remain high. We synthesize scientific evidence on the treatment of CSDH with biophysical principles and then propose a simple and effective surgical technique aiming to reduce the recurrence rate. Under local anesthesia, one burr hole is placed in the area above the maximum hematoma thickness. One drain is inserted into the dorsal direction to the deepest point of the hematoma cavity, and a second drain is inserted frontally into the highest point. Next, saline is gently instilled to the dorsal drain to eliminate air from the hematoma cavity through the frontal drain. Once saline has filled the frontal drain, the frontal drain is removed. The dorsal drain is left in situ for 48 h, and the pressure within the cavity may be adapted hydrostatically. We implemented evidence-based conclusions of previous studies and modified the classical burr-hole technique to reduce the recurrence rate. As a result, we developed a straightforward surgical procedure that is possible to perform under local anesthesia, suitable for everyday practice in rural and remote areas while working with limited resources. The novelty of this technique is in the purposeful reduction of postoperative pneumocephalus, a known independent factor of recurrence. Subdural air is eliminated during surgery using a two-drain system. Safety and efficacy of the technique need to be evaluated in future clinical trials.
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Affiliation(s)
- Martin Májovský
- Department of Neurosurgery and Neurooncology, First Faculty of Medicine of Charles University, Military University Hospital, Prague, Czech Republic
| | - David Netuka
- Department of Neurosurgery and Neurooncology, First Faculty of Medicine of Charles University, Military University Hospital, Prague, Czech Republic
| | - Vladimír Beneš
- Department of Neurosurgery and Neurooncology, First Faculty of Medicine of Charles University, Military University Hospital, Prague, Czech Republic
| | - Pavel Kučera
- Department of Natural Sciences, Faculty of Biomedical Engineering, Czech Technical University, Prague, Czech Republic.,Department of Physiology, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
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11
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Liu LX, Cao XD, Ren YM, Zhou LX, Yang CH. Risk Factors for Recurrence of Chronic Subdural Hematoma: A Single Center Experience. World Neurosurg 2019; 132:e506-e513. [PMID: 31450003 DOI: 10.1016/j.wneu.2019.08.089] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 08/12/2019] [Accepted: 08/14/2019] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Chronic subdural hematoma (CSDH) is a common form of intracranial hemorrhage with a substantial recurrence rate. We aimed to investigate the predictive factors for the postsurgical recurrence of CSDH. METHODS We retrospectively reviewed the medical records of patients with CSDH who underwent surgery in West China Hospital between January 2012 and June 2018. Univariate and multivariate analyses were performed to identify the relationships between recurrence of CSDH and factors such as age, sex, history of injury, Markwalder grading, computed tomography findings, surgical methods, and outcomes. RESULTS A total of 328 patients (281 men and 47 women) aged 22-93 years (mean age, 65.14 ± 13.76 years) were included. Computed tomography findings at admission showed mixed density hematoma in 136 patients, isodensity hematoma in 140, high-density hematoma in 34, and low-density hematoma in 18. The mortality and recurrence rate were 0.30% (1 of 328) and 2.44% (8 of 328), respectively. Six months postoperatively, 327 patients had Markwalder grade 0. Hematoma recurred in 8 patients of which 7 were mixed density hematoma and 1 was isodensity hematoma. Six patients who underwent craniotomy had thickened inner neomembrane that was resected. Univariate and multivariate analyses found mixed density hematoma to be an independent risk factor for the recurrence of CSDH. CONCLUSIONS Burr hole craniostomy with irrigation and closed-system drainage is effective for the surgical treatment of CSDH. Mixed density hematoma is an independent predictor for the recurrence of CSDH. Presence of thick inner neomembrane might be the primary cause of CSDH recurrence.
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Affiliation(s)
- Lun-Xin Liu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Xu-Dong Cao
- Department of Neurosurgery, The People's Hospital of Tibet Autonomous Region, Lhasa, Tibet, People's Republic of China
| | - Yan-Ming Ren
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Liang-Xue Zhou
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Chao-Hua Yang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China.
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12
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Ridwan S, Bohrer AM, Grote A, Simon M. Surgical Treatment of Chronic Subdural Hematoma: Predicting Recurrence and Cure. World Neurosurg 2019; 128:e1010-e1023. [DOI: 10.1016/j.wneu.2019.05.063] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 05/06/2019] [Accepted: 05/07/2019] [Indexed: 01/03/2023]
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13
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Wang C, Niu X, Ren Y, Lan Z, Zhang Y. Risk Factors for Postoperative Intracranial Hemorrhage After Resection of Intracranial Tumor in 2259 Consecutive Patients. World Neurosurg 2019; 129:e663-e668. [PMID: 31176060 DOI: 10.1016/j.wneu.2019.05.239] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 05/27/2019] [Accepted: 05/28/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Postoperative hemorrhage (POH), an uncommon complication after cranial operation, may result in prolonged postoperative hospitalization, severe neurologic impairment, or even death. Most models in studies detecting risk factors for POH include all kinds of cranial lesions; however, factors associated with POH may vary among intracranial diseases. There is a paucity of large sample studies focusing solely on POH after intracranial tumor surgery. Therefore, this study was designed to investigate the preoperative risk factors for POH after surgery for intracranial tumor. METHODS Medical records of 2259 adult patients who underwent primary surgical resection of single intracranial tumor between January 2017 and June 2018 at West China Hospital of Sichuan University were retrospectively studied. Univariate and multivariate analyses were performed to identify the risk factors for POH after resection of intracranial tumor. RESULTS POH (defined as postoperative hematoma requiring surgical evacuation) occurred in 40 of 2259 patients (1.8%). Univariate analysis revealed that older age (P = 0.037, Wilcoxon-Mann-Whitney test), higher international normalized ratio (INR) (P = 0.037, Wilcoxon-Mann-Whitney test), and larger tumor size (P = 0.001, Wilcoxon-Mann-Whitney test) were significantly associated with POH. Then it was confirmed by multivariate analysis that all of the 3 factors (older age: P = 0.033, higher INR: P = 0.044, larger tumor size: P = 0.002) were independent risk factors for POH after removal of intracranial tumor. CONCLUSIONS Older age, higher INR, and larger tumor size were identified as independent risk factors for POH after resection of intracranial tumor in adults.
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Affiliation(s)
- Chenghong Wang
- Departments of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Xiaodong Niu
- Departments of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Yanming Ren
- Departments of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Zhigang Lan
- Departments of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Yuekang Zhang
- Departments of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China.
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14
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Lee KS. How to Treat Chronic Subdural Hematoma? Past and Now. J Korean Neurosurg Soc 2018; 62:144-152. [PMID: 30486622 PMCID: PMC6411568 DOI: 10.3340/jkns.2018.0156] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 07/16/2018] [Indexed: 11/27/2022] Open
Abstract
Treatment of chronic subdural hematoma (CSDH) is relatively straightforward, however, there is still some debate regarding the best strategy for treatment. The most practical recommendations of up to date were identified by a review of literature. The author reviewed the literature on CSDH management from the past to now to identify the best methods. Till 1970s, craniotomy was the most commonly used method. Burr hole (BH) became the most preferred method from 1980s. In 1977, twist drill (TD) craniostomy was introduced. Closed system drainage after a BH or a TD became the most frequently used surgical method. Although nonsurgical treatment is often successful, trephination has more advantages, such as rapid resolution of the symptoms and short period of hospitalization. Nonsurgical treatment is possible in asymptomatic patients with a small CSDH. For the symptomatic patients with CSDH, trephination is the treatment of choice, either by BH or TD. In gray zone between surgery and medical treatment, shared decision making can be an ideal approach. For the recurrent CSDHs, repeated trephination is still effective for patients with a low risk of recurrence. If the risk of recurrence is high, additional management would be helpful. For the refractory CSDHs, it is necessary to obliterate the subdural space.
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Affiliation(s)
- Kyeong-Seok Lee
- Department of Neurosurgery, Soonchunhyang University Chonan Hospital, Chonan, Korea
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15
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Xu C, Chen B, Xue L, Xia L, Yang X, Wei M, Hui X, Chen Q, Zheng J, Li Z, Tian X, Cheng G, Xiao F, Lu M. Randomized controlled study on the curative effects of twist-drill craniotomy and burr-hole craniotomy in the treatment of chronic subdural hematoma. Exp Ther Med 2018; 16:959-965. [PMID: 30116345 DOI: 10.3892/etm.2018.6265] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Accepted: 05/02/2018] [Indexed: 11/05/2022] Open
Abstract
The present randomized controlled study investigated the differences in the curative effects of twist-drill craniotomy (TDC) and burr-hole craniotomy (BHC) in the treatment of chronic subdural hematoma (CSDH). A total of 40 patients diagnosed with CSDH via head computed tomography (CT) who required surgical decompression from January 2016 to January 2017 were enrolled in the present study, and were randomly divided into a TDC group (n=20) and a BHC group (n=20). The modified Rankin scale (mRS) scores of patients were recorded prior to the operation, and at 48 h and 3 months after the operation. The differences in the mRS score (VmRS) among the groups were calculated using the Mann-Whitney U test. The 40 patients enrolled comprised 33 males and 7 females, and there were no significant differences in the general clinical characteristics between the two groups. In the BHC group, 3 patients had a pre-operative mRS score of 5 points, among which 2 cases died at 32 and 45 days after discharge. In the TDC group, 4 patients had a pre-operative mRS score of 5 points, among which 1 case died of epilepsy and pulmonary infection at 1 month after the operation. No difference in the mortality rate was present between the two groups. During the 3-month follow-up, head CT indicated that the intracranial hematoma in a total of 4 patients, including 3 cases in the TDC group and 1 case in the BHC group, completely disappeared. In the BHC group, 3 cases required a repeated incision and drainage after the first operation, while no secondary operation was required in any of the cases of the TDC group. The average length of stay at the hospital (LOS) after TDC was 9.00±2.91 days, which was significantly shorter than that after BHC (14.75±5.95 days). In the total sample of 40 patients, a longer LOS was associated with a higher risk of secondary operation due to recurrence after discharge. The variation value of the mRS score at 3 months after the operation and its ratio vs. the pre-operative score in the TDC group were significantly different from those in the BHC group, suggesting that the improvement of neurological function after TDC was significantly greater than that after BHC. Although 18 patients (90%) in the TDC group were cured, there was no significant difference from the cure rate in the BHC group [15 patients (75%)]. In conclusion, no significant differences were identified in the cure rate and the mortality rate of patients with CSDH after the two types of surgical treatment. However, the mRS score in the TDC group at 3 months after the operation exhibited a significantly greater improvement compared with that in the BHC group, and the overall LOS in the TDC group was significantly shorter than that in BHC group. Therefore, TDC is superior to BHC in the treatment of CSDH (trial registration no. ChiCTR-INR-16008368).
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Affiliation(s)
- Changsong Xu
- Department of Neurology, Huai'an First People's Hospital, Nanjing Medical University, Huai'an, Jiangsu 223300, P.R. China
| | - Bing Chen
- Department of Neurology, Huai'an First People's Hospital, Nanjing Medical University, Huai'an, Jiangsu 223300, P.R. China
| | - Liujun Xue
- Department of Neurology, Huai'an First People's Hospital, Nanjing Medical University, Huai'an, Jiangsu 223300, P.R. China
| | - Lei Xia
- Department of Neurology, Huai'an First People's Hospital, Nanjing Medical University, Huai'an, Jiangsu 223300, P.R. China
| | - Xiu Yang
- Department of Neurology, Huai'an First People's Hospital, Nanjing Medical University, Huai'an, Jiangsu 223300, P.R. China
| | - Ming Wei
- Department of Neurology, Huai'an First People's Hospital, Nanjing Medical University, Huai'an, Jiangsu 223300, P.R. China
| | - Xiaobo Hui
- Department of Neurosurgery, Huai'an First People's Hospital, Nanjing Medical University, Huai'an, Jiangsu 223300, P.R. China
| | - Quan Chen
- Department of Neurology, Huai'an First People's Hospital, Nanjing Medical University, Huai'an, Jiangsu 223300, P.R. China
| | - Jinlong Zheng
- Department of Neurology, Huai'an First People's Hospital, Nanjing Medical University, Huai'an, Jiangsu 223300, P.R. China
| | - Zhengming Li
- Department of Neurosurgery, Huai'an First People's Hospital, Nanjing Medical University, Huai'an, Jiangsu 223300, P.R. China
| | - Xiangyang Tian
- Department of Neurology, Huai'an First People's Hospital, Nanjing Medical University, Huai'an, Jiangsu 223300, P.R. China
| | - Guanliang Cheng
- Department of Neurology, Huai'an First People's Hospital, Nanjing Medical University, Huai'an, Jiangsu 223300, P.R. China
| | - Feng Xiao
- Department of Neurology, Huai'an First People's Hospital, Nanjing Medical University, Huai'an, Jiangsu 223300, P.R. China
| | - Min Lu
- Department of Rehabilitation Medicine, Huai'an First People's Hospital, Nanjing Medical University, Huai'an, Jiangsu 223300, P.R. China
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Evidence based diagnosis and management of chronic subdural hematoma: A review of the literature. J Clin Neurosci 2018; 50:7-15. [PMID: 29428263 DOI: 10.1016/j.jocn.2018.01.050] [Citation(s) in RCA: 110] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Accepted: 01/08/2018] [Indexed: 11/23/2022]
Abstract
Chronic subdural hematomas are encapsulated blood collections within the dural border cells with characteristic outer "neomembranes". Affected patients are more often male and typically above the age of 70. Imaging shows crescentic layering of fluid in the subdural space on a non-contrast computed tomography (CT) scan, best appreciated on sagittal or coronal reformats. Initial medical management involves reversing anticoagulant/antiplatelet therapies, and often initiation of anti-epileptic drugs (AEDs). Operative interventions, such as twist-drill craniostomy (TDC), burr-hole craniostomy (BHC), and craniotomy are indicated if imaging implies compression (maximum fluid collection thickness >1 cm) or the patient is symptomatic. The effectiveness of various surgical techniques remains poorly characterized, with sparse level 1 evidence, variable outcome measures, and various surgical techniques. Postoperatively, subdural drains can decrease recurrence and sequential compression devices can decrease embolic complications, while measures such as early mobilization and re-initiation of anticoagulation need further study. Non-operative management, including steroid therapy, etizolam, tranexamic acid, and angiotensin converting enzyme inhibitors (ACEI) also remain poorly studied. Recurrent hemorrhages are a major complication affecting around 10-20% of patients, and therefore close follow-up is essential.
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Hou K, Zhu X, Zhao J, Zhang Y, Gao X, Jiang K, Li G. Efficacy of Reinforced Restriction of Physical Activity on Chronic Subdural Hematoma: Prospective Pilot Study. World Neurosurg 2017; 110:e1011-e1016. [PMID: 29223519 DOI: 10.1016/j.wneu.2017.11.155] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Revised: 11/24/2017] [Accepted: 11/27/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Chronic subdural hematoma (CSDH) is a common entity in neurosurgical practice. However, as a result of the high rate in recurrence, morbidity, and mortality for surgical management, conservative management of CSDH is emerging as a new treatment strategy. Head trauma is a known risk factor of CSDH and plays as an initiator in the genesis of CSDH. We hypothesized that physical activity might also play an important role in the progression of an asymptomatic CSDH. METHODS A prospective pilot study aiming to evaluate the efficacy of reinforced restriction of physical activity for the management of asymptomatic or mild symptomatic CSDH was conducted. Twenty-six patients were enrolled in this study. RESULTS All 26 patients experienced complete resolution of the CSDH ranging from 32 to 182 days (73.1 ± 19.6 days) since the initiation of reinforced restriction of physical activity. Ages ranged from 43 to 84 years old (64.4 ± 9.6 years). No patient experienced recurrence of CSDH during the follow-up. CONCLUSIONS According to our study, physical activity might play a role in the progression of CSDH. Further prospective randomized controlled study is warranted in stable patients without evident intracranial hypertension and impending cerebral herniation.
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Affiliation(s)
- Kun Hou
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Xiaobo Zhu
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Jinchuan Zhao
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Yang Zhang
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Xianfeng Gao
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Kai Jiang
- Department of Neurosurgery, The Second People's Hospital of Tonghua, Tonghua, Jilin, China
| | - Guichen Li
- Department of Neurology, The First Hospital of Jilin University, Changchun, Jilin, China.
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18
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Alliez JR. Ematoma subdurale cronico dell’adulto. Neurologia 2017. [DOI: 10.1016/s1634-7072(17)86805-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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19
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Brennan PM, Kolias AG, Joannides AJ, Shapey J, Marcus HJ, Gregson BA, Grover PJ, Hutchinson PJ, Coulter IC. The management and outcome for patients with chronic subdural hematoma: a prospective, multicenter, observational cohort study in the United Kingdom. J Neurosurg 2017; 127:732-739. [DOI: 10.3171/2016.8.jns16134] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVESymptomatic chronic subdural hematoma (CSDH) will become an increasingly common presentation in neurosurgical practice as the population ages, but quality evidence is still lacking to guide the optimal management for these patients. The British Neurosurgical Trainee Research Collaborative (BNTRC) was established by neurosurgical trainees in 2012 to improve research by combining the efforts of trainees in each of the United Kingdom (UK) and Ireland's neurosurgical units (NSUs). The authors present the first study by the BNTRC that describes current management and outcomes for patients with CSDH throughout the UK and Ireland. This provides a resource both for current clinical practice and future clinical research on CSDH.METHODSData on management and outcomes for patients with CSDH referred to UK and Ireland NSUs were collected prospectively over an 8-month period and audited against criteria predefined from the literature: NSU mortality < 5%, NSU morbidity < 10%, symptomatic recurrence within 60 days requiring repeat surgery < 20%, and unfavorable functional status (modified Rankin Scale score of 4–6) at NSU discharge < 30%.RESULTSData from 1205 patients in 26 NSUs were collected. Bur-hole craniostomy was the most common procedure (89%), and symptomatic recurrence requiring repeat surgery within 60 days was observed in 9% of patients. Criteria on mortality (2%), rate of recurrence (9%), and unfavorable functional outcome (22%) were met, but morbidity was greater than expected (14%). Multivariate analysis demonstrated that failure to insert a drain intraoperatively independently predicted recurrence and unfavorable functional outcome (p = 0.011 and p = 0.048, respectively). Increasing patient age (p < 0.00001), postoperative bed rest (p = 0.019), and use of a single bur hole (p = 0.020) independently predicted unfavorable functional outcomes, but prescription of high-flow oxygen or preoperative use of antiplatelet medications did not.CONCLUSIONSThis is the largest prospective CSDH study and helps establish national standards. It has confirmed in a real-world setting the effectiveness of placing a subdural drain. This study identified a number of modifiable prognostic factors but questions the necessity of some common aspects of CSDH management, such as enforced postoperative bed rest. Future studies should seek to establish how practitioners can optimize perioperative care of patients with CSDH to reduce morbidity as well as minimize CSDH recurrence. The BNTRC is unique worldwide, conducting multicenter trainee-led research and audits. This study demonstrates that collaborative research networks are powerful tools to interrogate clinical research questions.
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Affiliation(s)
- Paul M. Brennan
- 1Department of Clinical Neurosciences, Western General Hospital, Edinburgh
| | - Angelos G. Kolias
- 2Division of Neurosurgery, Addenbrooke's Hospital and University of Cambridge, Cambridge
| | - Alexis J. Joannides
- 2Division of Neurosurgery, Addenbrooke's Hospital and University of Cambridge, Cambridge
| | - Jonathan Shapey
- 3Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London
| | - Hani J. Marcus
- 4Department of Neurosurgery, Charing Cross Hospital, London
| | | | | | - Peter J. Hutchinson
- 2Division of Neurosurgery, Addenbrooke's Hospital and University of Cambridge, Cambridge
| | - Ian C. Coulter
- 7Department of Neurosurgery, James Cook Hospital, Middleborough, United Kingdom;
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Abstract
Patients with cSDH presenting with new or worsening neurological deficits, especially if they are debilitating and adversely affecting quality of life require urgent medical and surgical attention. Neurological and neurosurgical critical care team need to stabilize the patient by reversing any underlying coagulopathy states in order to prevent further hematoma expansion.In the event of brain herniation and presumed ICP elevation and CPP compromise, step-wise ICP management should be instituted promptly.Seizure prophylaxis treatment is reasonable. Timing of surgical evacuation is not always easy to determine but the presence of significant neurological deficits with impending herniation require immediate surgical Intervention. Consideration of the clot density along with patient's current neurological status would determine the timing and type of surgical interventions. Postoperative critical care management is not trivial. In addition to detecting any changes in neurological conditions, timely initiation (typically within the first 48 hours if clinical and radiographic conditions are stable with no co-existing coagulopathy) of venous thromboembolism prophylaxis is essential. Resuming antiplatelets and anticoagulants are warranted for those with clear indications including atrial fibrillation, atrial thrombus, known deep vein thrombosis, mechanical heart valves and other preexisting hypercoagulable conditions, but it is generally advised to hold antiplatelets and anticoagulants for about 10-14 post injury and/or surgical intervention.
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Affiliation(s)
- Jeremy T Ragland
- Departments of Neurosurgery and Neurology, Division of Neurocritical Care McGovern Medical School, 6431 Fannin Street, Medical School Building 7.152, University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Kiwon Lee
- Departments of Neurosurgery and Neurology, Division of Neurocritical Care McGovern Medical School, 6431 Fannin Street, Medical School Building 7.152, University of Texas Health Science Center at Houston, Houston, TX 77030, USA.
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22
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Desai VR, Scranton RA, Britz GW. Management of Recurrent Subdural Hematomas. Neurosurg Clin N Am 2017; 28:279-286. [DOI: 10.1016/j.nec.2016.11.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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23
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Brennan PM, Kolias AG, Joannides AJ, Shapey J, Marcus HJ, Gregson BA, Grover PJ, Hutchinson PJ, Coulter IC. The management and outcome for patients with chronic subdural hematoma: a prospective, multicenter, observational cohort study in the United Kingdom. J Neurosurg 2017:1-8. [PMID: 28306417 DOI: 10.3171/2016.8.jns16134.test] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Symptomatic chronic subdural hematoma (CSDH) will become an increasingly common presentation in neurosurgical practice as the population ages, but quality evidence is still lacking to guide the optimal management for these patients. The British Neurosurgical Trainee Research Collaborative (BNTRC) was established by neurosurgical trainees in 2012 to improve research by combining the efforts of trainees in each of the United Kingdom (UK) and Ireland's neurosurgical units (NSUs). The authors present the first study by the BNTRC that describes current management and outcomes for patients with CSDH throughout the UK and Ireland. This provides a resource both for current clinical practice and future clinical research on CSDH. METHODS Data on management and outcomes for patients with CSDH referred to UK and Ireland NSUs were collected prospectively over an 8-month period and audited against criteria predefined from the literature: NSU mortality < 5%, NSU morbidity < 10%, symptomatic recurrence within 60 days requiring repeat surgery < 20%, and unfavorable functional status (modified Rankin Scale score of 4-6) at NSU discharge < 30%. RESULTS Data from 1205 patients in 26 NSUs were collected. Bur-hole craniostomy was the most common procedure (89%), and symptomatic recurrence requiring repeat surgery within 60 days was observed in 9% of patients. Criteria on mortality (2%), rate of recurrence (9%), and unfavorable functional outcome (22%) were met, but morbidity was greater than expected (14%). Multivariate analysis demonstrated that failure to insert a drain intraoperatively independently predicted recurrence and unfavorable functional outcome (p = 0.011 and p = 0.048, respectively). Increasing patient age (p < 0.00001), postoperative bed rest (p = 0.019), and use of a single bur hole (p = 0.020) independently predicted unfavorable functional outcomes, but prescription of high-flow oxygen or preoperative use of antiplatelet medications did not. CONCLUSIONS This is the largest prospective CSDH study and helps establish national standards. It has confirmed in a real-world setting the effectiveness of placing a subdural drain. This study identified a number of modifiable prognostic factors but questions the necessity of some common aspects of CSDH management, such as enforced postoperative bed rest. Future studies should seek to establish how practitioners can optimize perioperative care of patients with CSDH to reduce morbidity as well as minimize CSDH recurrence. The BNTRC is unique worldwide, conducting multicenter trainee-led research and audits. This study demonstrates that collaborative research networks are powerful tools to interrogate clinical research questions.
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Affiliation(s)
- Paul M Brennan
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh
| | - Angelos G Kolias
- Division of Neurosurgery, Addenbrooke's Hospital and University of Cambridge, Cambridge
| | - Alexis J Joannides
- Division of Neurosurgery, Addenbrooke's Hospital and University of Cambridge, Cambridge
| | - Jonathan Shapey
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London
| | - Hani J Marcus
- Department of Neurosurgery, Charing Cross Hospital, London
| | - Barbara A Gregson
- Neurosurgical Trials Group, Newcastle University, Newcastle upon Tyne
| | | | - Peter J Hutchinson
- Division of Neurosurgery, Addenbrooke's Hospital and University of Cambridge, Cambridge
| | - Ian C Coulter
- Department of Neurosurgery, James Cook Hospital, Middleborough, United Kingdom
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Sivaraju L, Moorthy RK, Jeyaseelan V, Rajshekhar V. Routine placement of subdural drain after burr hole evacuation of chronic and subacute subdural hematoma: a contrarian evidence based approach. Neurosurg Rev 2017; 41:165-171. [DOI: 10.1007/s10143-017-0831-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 02/05/2017] [Accepted: 02/08/2017] [Indexed: 01/09/2023]
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25
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Outcome following surgical treatment of chronic subdural hematoma in the oldest-old population. Neurosurg Rev 2016; 40:461-468. [DOI: 10.1007/s10143-016-0803-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 11/16/2016] [Accepted: 12/06/2016] [Indexed: 10/20/2022]
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Papacocea T, Adam D, Croitoru R, Rusu I, Papacocea A. Factors influencing the recurrence rate of operated chronic subdural hematomas. ROMANIAN NEUROSURGERY 2016. [DOI: 10.1515/romneu-2016-0026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
AbstractIn this study we are trying to establish a correlation between the surgical technique used for the treatment of chronic subdural hematomas and the risk of recurrence. Between 01.06.2008 and 31.05.2014, 123 patients with 138 chronic subdural hematomas (CSDH) were operated on and followed-up in our department. Among them, 16 hematomas (11,6%) recurred. Factors related to the patients (gender, age, location of the hematoma) are analyzed as possible predictors of recurrence. Several surgical techniques were used in the treatment of chronic subdural hematomas. Each of them is analyzed to find possibly connections with the recurrence risk of the size of the approach, the reposition of the bone flap, the suture of the dura and other aspects. There are obvious, statistically significant correlations between the risk of recurrence and some elements of the surgical technique employed.
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Shapey J, Glancz LJ, Brennan PM. Chronic Subdural Haematoma in the Elderly: Is It Time for a New Paradigm in Management? CURRENT GERIATRICS REPORTS 2016; 5:71-77. [PMID: 27213133 PMCID: PMC4851686 DOI: 10.1007/s13670-016-0166-9] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Chronic subdural haematoma (CSDH) is a common neurological condition that usually affects the elderly. The optimal treatment strategy remains uncertain, principally because there is a lack of a good evidence base. In this paper, we review the literature concerning the peri-operative and operative care of patients. In particular, we highlight the non-surgical aspects of care that might impact on patient outcomes and CSDH recurrence. We propose that an integrated approach to care in patients with CSDH, similar to care of fragility fractures in the elderly, may be an important strategy to improve patient care and outcomes.
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Affiliation(s)
- J. Shapey
- />National Hospital for Neurology and Neurosurgeon, Queen Square, London, UK
| | - L. J. Glancz
- />Department of Neurosurgery, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - P. M. Brennan
- />Department of Clinical Neurosciences, Western General Hospital, University of Edinburgh, Edinburgh, UK
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Ivamoto HS, Lemos HP, Atallah AN. Surgical Treatments for Chronic Subdural Hematomas: A Comprehensive Systematic Review. World Neurosurg 2015; 86:399-418. [PMID: 26485412 DOI: 10.1016/j.wneu.2015.10.025] [Citation(s) in RCA: 112] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2015] [Revised: 09/30/2015] [Accepted: 10/01/2015] [Indexed: 11/15/2022]
Abstract
BACKGROUND Chronic subdural hematomas (CSDHs) are common neurosurgical conditions among elderly patients. OBJECTIVE To perform a detailed critical appraisal of all randomized controlled trials (RCTs) of surgical treatments for chronic subdural hematomas and to quantify their intervention effects. METHODS We performed a broad search for all RCTs with no language or date restrictions, asked the authors for missing data, and applied the Cochrane methods. RESULTS A total of 24 RCTs involved 1900 patients and 15 comparisons. All outcomes of practical interest were analyzed. Postoperative drainage after burr-hole evacuation reduced the rate of recurrence (risk ratio 0.48, 95% confidence interval 0.34-0.66, P < 0.00001) with no other clear benefits or complications. CONCLUSIONS This comprehensive, best evidence-based, quantitative, systematic review indicates that the use of a closed system drainage after burr-hole evacuation reduces the rate of recurrences but has no other significant differences. The findings also suggest that: (1) treatment with twist drills is equivalent to that with burr holes; (2) the postoperative bed header in the elevated position might reduce the length of hospital stay; (3) irrigation of the subdural space with thrombin solution in patients with high risk of recurrence might reduce this risk; and (4) treatment with twist drill followed by a closed system drainage during 48 hours, instead of 96 hours, might reduce general complication rates. Most of the trials suffered from unclear or high risks of bias and many involved small samples, precluding strong and definitive conclusions.
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Affiliation(s)
- Henrique Seiji Ivamoto
- Federal University of Sao Paulo Postgraduate Program on Evidence-Based Health Care, Brazilian Cochrane Centre.
| | - Hernani Pinto Lemos
- Federal University of Sao Paulo Postgraduate Program on Evidence-Based Health Care, Brazilian Cochrane Centre
| | - Alvaro Nagib Atallah
- Federal University of Sao Paulo Postgraduate Program on Evidence-Based Health Care, Brazilian Cochrane Centre
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Comparison of subgaleal and subdural closed drainage system in the surgical treatment of chronic subdural hematoma. North Clin Istanb 2015; 2:115-121. [PMID: 28058351 PMCID: PMC5175088 DOI: 10.14744/nci.2015.06977] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 06/25/2015] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE: One or two burr-hole craniostomies with subgaleal or subdural drainage system and irrigation are the most common methods for surgical treatment of CSDH. The aim of this study is to compare the advantages or disadvantages of these techniques used for CSDH. METHODS: Seventy patients were treated by burr-hole subdural drainage or subgaleal drainage system with irrigation. Our patients were classified into two groups according to the operative procedure as follows: Group I, one or two burr-hole craniostomy with subgaleal closed system drainage and irrigation (n=36), Group II, one or two burr-hole craniostomies with subdural closed drainage system and irrigation (n=38). We compared male and female ratios, complication rates, and age distribution between groups. RESULTS: There was no remarkable difference between recurrence rates of the two groups. Recurrence rate was 6.25% in Group I and 7.8% in Group II. Subdural empyema occurred in one of the patients in Group II. Symptomatic pneumocephalus did not develop in patients. Four patients were reoperated for recurrence at an average of 12–20 days after the operation with the same methods. CONCLUSION: Both of the techniques have a higher cure rate and a lower risk of recurrence. However, subgaleal drainage system is relatively less invasive, safe, and technically easy. So it is applicable for aged and higher risk patients.
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Lin MS, Chang CJ, Lin CC, Chen ST, Hwang B, Lu SH. Quantitative assessment of brain shifting in the late phase postevacuation in unilateral and bilateral chronic subdural hematomas. Int J Neurosci 2015; 126:617-22. [PMID: 26005046 DOI: 10.3109/00207454.2015.1051044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
AIM OF THE STUDY Recurrence is more common in bilateral chronic subdural hematomas (CSDHs) than in unilateral. Our aim was to quantitatively compare the late phase of brain shifting postevacuation in unilateral and bilateral CSDHs. MATERIALS AND METHODS We reviewed computed tomography (CT) scans and medical records of consecutive patients with CSDHs who underwent burr hole drainage. CT scan images (preoperative and postoperative days [PODs] 30 and 60) were imported to Adobe Photoshop, and temporal and spatial changes in brain shifting between PODs 30 and 60, and also the subdural space on POD 60, were analyzed. RESULTS The bilateral group exhibited a significantly greater late phase of brain shifting than the unilateral group between PODs 30 and 60 (P < 0.001). The median late phase of brain shifting of the bilateral group was 8.9 mm (interquartile range [IQR]: 8.3-9.0 mm) between PODs 30 and 60, while that of the unilateral group was 1.8 mm (IQR: 1.3-2.5 mm). CONCLUSIONS The postevacuation late phase of brain shifting is statistically greater in bilateral CSDHs than in unilateral CSDHs, which might facilitate bridging vein tearing and consequent rebleeding. This may be one factor accounting for the higher recurrence rate of bilateral CSDHs.
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Affiliation(s)
- Muh-Shi Lin
- a Department of Surgery, Faculty of Medicine, School of Medicine , tf:institution-nameNational Yang-Ming University , Taipei , Taiwan.,b Department of Neurosurgery, Zhong Xiao Branch, Taipei City Hospital , Taipei , Taiwan.,c Department of Biotechnology and Animal Science, College of Bioresources , National Ilan University , Yilan , Taiwan
| | - Cheng-Jen Chang
- d Department of Plastic Surgery, Aesthetic Medical Center, Chang Gung Memorial Hospital , Chang Gung University College of Medicine , Taoyuan , Taiwan
| | - Chai-Ching Lin
- c Department of Biotechnology and Animal Science, College of Bioresources , National Ilan University , Yilan , Taiwan
| | - Shuo-Tsung Chen
- e Department of Mathematics , Tunghai University , Taichung , Taiwan
| | - Betau Hwang
- f Department of Pediatrics, Faculty of Medicine, School of Medicine , National Yang-Ming University , Taipei , Taiwan.,g Department of Pediatrics, Zhong Xiao Branch, Taipei City Hospital , Taipei , Taiwan
| | - Shing-Hwa Lu
- h Department of Urology, Zhong Xiao Branch, Taipei City Hospital , Taipei , Taiwan.,i Department of Urology, Faculty of Medicine, School of Medicine , National Yang-Ming University , Taipei , Taiwan
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Embolization of the Middle Meningeal Artery Effectively Treats Refractory Chronic Subdural Hematoma: A Systematic Review. ROMANIAN NEUROSURGERY 2014. [DOI: 10.2478/romneu-2014-0034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
AbstractChronic subdural hematoma (CSDH) formation mechanism is very complex, and has not entirely understood. It represents a frequent type of intracranial hemorrhage, and is very common disease in Neurosurgery practice, especially in older patients. Various surgical treatments have been proposed for the treatment of CSDH. The rate of recurrence in CSDH after surgery ranges from 5% to 30%, repeated surgery must be considered. But in some cases subdural collections are still persistent. Endovascular embolization of the middle meningeal artery (MMA) is an option for treatment of refractory CSDH. We review all cases that were treated with embolization to assess the effect of this intervention. Our review revealed 6 papers with a total enrollment of 14 patients were treated with MMA embolization for refractory chronic subdural hematoma without any postoperative complication or recurrence. In this study we suggest MMA embolization as an alternative for treatment of non-curable CSDH, especially for old people with systematic diseases, who cannot tolerate repeat surgery.
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Abstract
Chronic subdural haematoma (CSDH) is one of the most common neurological disorders, and is especially prevalent among elderly individuals. Surgical evacuation is the mainstay of management for symptomatic patients or haematomas exerting significant mass effect. Although burr hole craniostomy is the most widely practised technique worldwide, approximately 10-20% of surgically treated patients experience postoperative recurrence necessitating reoperation. Given the increasing incidence of CSDH in a growing elderly population, a need exists for refined techniques that combine a minimally invasive approach with clinical efficacy and cost-effectiveness. In addition, nonsurgical treatment modalities, such as steroids, are attracting considerable interest, as they have the potential to reduce postoperative recurrence or even replace the need for surgery in selected patients. This Review provides an overview of the contemporary management of CSDH and presents considerations regarding future approaches that could further optimize patient care and outcomes.
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Liu W, Bakker NA, Groen RJM. Chronic subdural hematoma: a systematic review and meta-analysis of surgical procedures. J Neurosurg 2014; 121:665-73. [DOI: 10.3171/2014.5.jns132715] [Citation(s) in RCA: 152] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
In this paper the authors systematically evaluate the results of different surgical procedures for chronic subdural hematoma (CSDH).
Methods
The MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and other databases were scrutinized according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) statement, after which only randomized controlled trials (RCTs) and quasi-RCTs were included. At least 2 different neurosurgical procedures in the management of chronic subdural hematoma (CSDH) had to be evaluated. Included studies were assessed for the risk of bias. Recurrence rates, complications, and outcome including mortality were taken as outcome measures. Statistical heterogeneity in each meta-analysis was assessed using the T2 (tau-squared), I2, and chi-square tests. The DerSimonian-Laird method was used to calculate the summary estimates using the fixed-effect model in meta-analysis.
Results
Of the 297 studies identified, 19 RCTs were included. Of them, 7 studies evaluated the use of postoperative drainage, of which the meta-analysis showed a pooled OR of 0.36 (95% CI 0.21–0.60; p < 0.001) in favor of drainage. Four studies compared twist drill and bur hole procedures. No significant differences between the 2 methods were present, but heterogeneity was considered to be significant. Three studies directly compared the use of irrigation before drainage. A fixed-effects meta-analysis showed a pooled OR of 0.49 (95% CI 0.21–1.14; p = 0.10) in favor of irrigation. Two studies evaluated postoperative posture. The available data did not reveal a significant advantage in favor of the postoperative supine posture. Regarding positioning of the catheter used for drainage, it was shown that a frontal catheter led to a better outcome. One study compared duration of drainage, showing that 48 hours of drainage was as effective as 96 hours of drainage.
Conclusions
Postoperative drainage has the advantage of reducing recurrence without increasing complications. The use of a bur hole or twist drill does not seem to make any significant difference in recurrence rates or other outcome measures. It seems that irrigation may lead to a better outcome. These results may lead to more standardized procedures.
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Affiliation(s)
- Weiming Liu
- 1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, China; and
| | - Nicolaas A. Bakker
- 2Department of Neurosurgery, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Rob J. M. Groen
- 2Department of Neurosurgery, University Medical Center Groningen, University of Groningen, The Netherlands
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Posicionamiento postoperatorio de la cabecera tras drenaje de hematomas subdurales crónicos por trepanación: Revisión sistemática y metaanálisis de estudios controlados aleatorizados. Neurocirugia (Astur) 2014; 25:99-107. [DOI: 10.1016/j.neucir.2013.11.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Revised: 10/21/2013] [Accepted: 11/28/2013] [Indexed: 11/22/2022]
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Coulter IC, Kolias AG, Marcus HJ, Ahmed AI, Alli S, Al-Mahfoudh R, Borg A, Cowie CJA, Hill CS, Joannides AJ, Jones TL, Kailaya-Vasan A, Livermore JL, Narayanamurthy H, Ngoga D, Shapey J, Tarnaris A, Gregson BA, Gray WP, Nelson RJ, Hutchinson PJ, Brennan PM. Proposal for a prospective multi-centre audit of chronic subdural haematoma management in the United Kingdom and Ireland. Br J Neurosurg 2013; 28:199-203. [PMID: 24053314 DOI: 10.3109/02688697.2013.835378] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND. Chronic subdural haematoma (CSDH) is a common condition that increases in incidence with rising age. Evacuation of a CSDH is one of the commonest neurosurgical procedures; however the optimal peri-operative management, surgical technique, post-operative care and the role of adjuvant therapies remain controversial. AIM. We propose a prospective multi-centre audit in order to establish current practices, outcomes and national benchmarks for future studies. METHODS. Neurosurgical units (NSU) in the United Kingdom and Ireland will be invited to enrol patients to this audit. All adult patients aged 16 years and over with a primary or recurrent CSDH will be eligible for inclusion. OUTCOME MEASURES AND ANALYSIS. The proposed outcome measures are (1) clinical recurrence requiring re-operation within 60 days; (2) modified Rankin scale (mRS) score at discharge from NSU; (3) morbidity and mortality in the NSU; (4) destination at discharge from NSU and (5) length of stay in the NSU. Audit standards have been derived from published systematic reviews and a recent randomised trial. The proposed standards are clinical recurrence rate < 20%; unfavourable mRS (4-6) at discharge from NSU < 30%; mortality rate in NSU < 5%; morbidity rate in NSU < 10%. Data will be submitted directly into a secure online database and analysed by the study's management group. CONCLUSIONS. The audit will determine the contemporary management and outcomes of patients with CSDH in the United Kingdom and Ireland. It will inform national guidelines, clinical practice and future studies in order to improve the outcome of patients with CSDH.
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Affiliation(s)
- Ian C Coulter
- Department of Neurosurgery, James Cook University Hospital , Middlesbrough , UK
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Sousa EB, Brandão LFS, Tavares CB, Borges IBC, Neto NGF, Kessler IM. Epidemiological characteristics of 778 patients who underwent surgical drainage of chronic subdural hematomas in Brasília, Brazil. BMC Surg 2013; 13:5. [PMID: 23452673 PMCID: PMC3616905 DOI: 10.1186/1471-2482-13-5] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2012] [Accepted: 02/13/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chronic subdural hematomas (CSDHs) are common in neurosurgical practice. There are no publications that report large series of the epidemiological characteristics of this pathology in Brazil. The purpose is to describe a large series of surgical cases and analyze the epidemiological and clinical characteristics. METHODS We retrospectively analyzed patients with CSDH admitted into Neurosurgical Services at the Hospital de Base do Distrito Federal, Brasília, Brazil from 2006 to 2011. Age, sex, clinical feature, etiology, surgical procedure, side, clinical outcome, and recurrence were reviewed. Statistical tests were used to analyze data, and P < 0.05 was considered statistically significant. RESULTS The series included 778 patients. There were 643 (82.6%) male patients with a mean age of 64.3 ± 15.9 (range, 14-93) years. The principal symptom was headache (58.9%). The most frequent origin was a fall (282 cases, 36.2%), but the origin remained unclear in 281 (36.1%) patients. Mild head injury occurred in 540 (69.4%) cases. Burr holes with drainage were used as the surgical procedure in 96.5% patients, and 687 (88.3%) patients had a positive outcome. Mortality was 0%. Recurrence was observed in 42 cases. CONCLUSIONS The occurrence of CSDHs is more common in elderly men. Treatment with burr holes and drainage is a simple and safe method for treatment. In our experience, CSDH presents decreased morbidity and mortality.
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Affiliation(s)
- Emerson B Sousa
- Service of Neurosurgery at the Hospital de Base do Distrito Federal, Brasília, Brazil.
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Effects of Newly Designed Drainage Catheter in Treating Chronic Subdural Hematoma. Korean J Neurotrauma 2013. [DOI: 10.13004/kjnt.2013.9.2.87] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Chon KH, Lee JM, Koh EJ, Choi HY. Independent predictors for recurrence of chronic subdural hematoma. Acta Neurochir (Wien) 2012; 154:1541-8. [PMID: 22653496 DOI: 10.1007/s00701-012-1399-9] [Citation(s) in RCA: 141] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2012] [Accepted: 05/15/2012] [Indexed: 12/14/2022]
Abstract
BACKGROUND Chronic subdural hematoma is characterized by blood in the subdural space that evokes an inflammatory reaction. Numerous factors potentially associated with recurrence of chronic subdural hematoma have been reported, but these factors have not been sufficiently investigated. In this study, we evaluated the independent risk factors of recurrence. METHODS We analyzed data for 420 patients with chronic subdural hematoma treated by the standard surgical procedure for hematoma evacuation at our institution. RESULTS Ninety-two (21.9 %) patients experienced at least one recurrence of chronic subdural hematoma during the study period. We did not identify any significant differences between chronic subdural hematoma recurrence and current antiplatelet therapy. The recurrence rate was 7 % for the homogeneous type, 21 % for the laminar type, 38 % for the separated type, and 0 % for the trabecular type. The rate of recurrence was significantly lower in the homogeneous and trabecular type than in the laminar and separated type. We performed a multivariate logistic regression analysis and found that postoperative midline shifting (OR, 3.6; 95 % CI, 1.618-7.885; p = 0.001), diabetes mellitus (OR, 2.2; 95 % CI, 1.196-3.856; p = 0.010), history of seizure (OR, 2.6; 95 % CI, 1.210-5.430; p = 0.014), width of hematoma (OR, 2.1; 95 % CI, 1.287-3.538; p = 0.003), and anticoagulant therapy (OR, 2.7; 95 % CI, 1.424-6.960; p = 0.005) were independent risk factors for the recurrence of chronic subdural hematoma. CONCLUSIONS We have shown that postoperative midline shifting (≥5 mm), diabetes mellitus, preoperative seizure, preoperative width of hematoma (≥20 mm), and anticoagulant therapy were independent predictors of the recurrence of chronic subdural hematoma. According to internal architecture of hematoma, the rate of recurrence was significantly lower in the homogeneous and the trabecular type than the laminar and separated type.
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Affiliation(s)
- Kyu-Hyon Chon
- Department of Neurosurgery, Chonbuk National University Hospital & Medical School, 664-14, Deokjin-Gu, Jeonju, Jeonbuk, 561-756, Republic of Korea
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Ohba S, Kinoshita Y, Nakagawa T, Murakami H. The risk factors for recurrence of chronic subdural hematoma. Neurosurg Rev 2012; 36:145-9; discussion 149-50. [PMID: 22696158 DOI: 10.1007/s10143-012-0396-z] [Citation(s) in RCA: 99] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2011] [Revised: 10/18/2011] [Accepted: 04/14/2012] [Indexed: 12/15/2022]
Abstract
Chronic subdural hematoma (CSDH) is a common disease in the elderly, and the recurrence rate of CSDH is reported to range from 2.3 to 33%. We performed a retrospective review of a number of CSDH cases and the potential factors associated with CSDH recurrence. The patient population comprised 112 men and 65 women with a mean age of 74.7 years. We analyzed the following factors: age, sex, antiplatelet and anticoagulant use, hematoma laterality, hematoma thickness, degree of midline shift and internal architecture of the hematoma in the preoperative CT films, use of irrigation, direction of the drainage tube, width of the subdural space, and degree of midline shift and the presence of a massive subdural air collection in the postoperative CT films. Univariate analysis revealed that there was a trend for different rates of recurrence among the different types of hematomas. The presence of a postoperative massive subdural air collection tended to be associated with the recurrence of hematoma. Multivariate analysis revealed that separated hematomas were significantly associated with CSDH recurrence, whereas the presence of postoperative massive subdural air collection tended to be associated with hematoma recurrence. Neither univariate nor multivariate analysis could demonstrate an association between the direction of the drainage tube and the recurrence of CSDH.
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Affiliation(s)
- Shigeo Ohba
- Department of Neurosurgery, Ashikaga Red Cross Hospital, 3-2100 Honjo, Ashikaga City, Tochigi, 326-0808, Japan.
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Kung WM, Hung KS, Chiu WT, Tsai SH, Lin JW, Wang YC, Lin MS. Quantitative assessment of impaired postevacuation brain re-expansion in bilateral chronic subdural haematoma: possible mechanism of the higher recurrence rate. Injury 2012; 43:598-602. [PMID: 20850740 DOI: 10.1016/j.injury.2010.07.240] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2009] [Revised: 05/03/2010] [Accepted: 07/12/2010] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Recurrence of chronic subdural haematoma (CSDH) occurs in up to 30% of patients. The rate of recurrence is higher in bilateral versus unilateral CSDH and the reason for this has not been fully elucidated. There are few quantitative studies of temporal changes in brain re-expansion after haematoma evacuation. The aim of this study is to use a simple volumetric image analysis method to quantify temporal changes of postoperative brain re-expansion in unilateral and bilateral CSDH. METHODS We reviewed computed tomography (CT) scans of 20 consecutive patients (16 men, 4 women; median age, 73.5 years) with CSDH (unilateral, n=10; bilateral, n=10) who underwent surgery (burr hole drainage on one or both sides) at our institutions during the period from June 2006 to August 2008. Haematoma volume was quantified preoperatively and on postoperative days 14 and 30 by computer-based image analysis (PACS Web 1000 System) of CT scans. We then calculated the brain re-expansion rate (BRR) for postoperative days 14 and 30. RESULTS Haematoma volume remained significantly higher (p<0.001) in bilateral versus unilateral CSDHs at both postoperative time points, and the BRR was significantly greater (p<0.001) in unilateral versus bilateral CSDH at both time points. CONCLUSION Results of this quantitative analysis provide definitive evidence for a poor BRR in bilateral compared to unilateral CSDH. This impairment may result in shifting of the brain and shearing of blood vessels, resulting in a higher recurrence rate.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Cohort Studies
- Craniotomy/methods
- Drainage/methods
- Evaluation Studies as Topic
- Female
- Hematoma, Subdural, Chronic/epidemiology
- Hematoma, Subdural, Chronic/pathology
- Hematoma, Subdural, Chronic/prevention & control
- Hematoma, Subdural, Chronic/surgery
- Humans
- Male
- Middle Aged
- Postoperative Complications
- Secondary Prevention
- Tomography, X-Ray Computed
- Treatment Outcome
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Affiliation(s)
- Woon-Man Kung
- Department of Neurosurgery, Taipei Medical University-Wan Fang Hospital, Taipei, Taiwan
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The Influence of Postoperative Lesion-Down Head Position on the Recurrence Rate in Chronic Subdural Hematoma after Burr-Hole Surgery. Korean J Neurotrauma 2012. [DOI: 10.13004/kjnt.2012.8.2.134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Singh SK, Sinha M, Singh VK, Parihar A, Srivastava C, Ojha BK, Chandra A. A randomized study of twist drill versus burr hole craniostomy for treatment of chronic subdural hematomas in 100 patients. INDIAN JOURNAL OF NEUROTRAUMA 2011. [DOI: 10.1016/s0973-0508(11)80005-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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The surgical management of chronic subdural hematoma. Neurosurg Rev 2011; 35:155-69; discussion 169. [PMID: 21909694 DOI: 10.1007/s10143-011-0349-y] [Citation(s) in RCA: 300] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2010] [Revised: 04/02/2011] [Accepted: 05/15/2011] [Indexed: 12/14/2022]
Abstract
Chronic subdural hematoma (cSDH) is an increasingly common neurological disease process. Despite the wide prevalence of cSDH, there remains a lack of consensus regarding numerous aspects of its clinical management. We provide an overview of the epidemiology and pathophysiology of cSDH and discuss several controversial management issues, including the timing of post-operative resumption of anticoagulant medications, the effectiveness of anti-epileptic prophylaxis, protocols for mobilization following evacuation of cSDH, as well as the comparative effectiveness of the various techniques of surgical evacuation. A PubMed search was carried out through October 19, 2010 using the following keywords: "subdural hematoma", "craniotomy", "burr-hole", "management", "anticoagulation", "seizure prophylaxis", "antiplatelet", "mobilization", and "surgical evacuation", alone and in combination. Relevant articles were identified and back-referenced to yield additional papers. A meta-analysis was then performed comparing the efficacy and complications associated with the various methods of cSDH evacuation. There is general agreement that significant coagulopathy should be reversed expeditiously in patients presenting with cSDH. Although protocols for gradual resumption of anti-coagulation for prophylaxis of venous thrombosis may be derived from guidelines for other neurosurgical procedures, further prospective study is necessary to determine the optimal time to restart full-dose anti-coagulation in the setting of recently drained cSDH. There is also conflicting evidence to support seizure prophylaxis in patients with cSDH, although the existing literature supports prophylaxis in patients who are at a higher risk for seizures. The published data regarding surgical technique for cSDH supports primary twist drill craniostomy (TDC) drainage at the bedside for patients who are high-risk surgical candidates with non-septated cSDH and craniotomy as a first-line evacuation technique for cSDH with significant membranes. Larger prospective studies addressing these aspects of cSDH management are necessary to establish definitive recommendations.
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A Randomized Controlled Trial Comparing the Outcome of Burr-Hole Irrigation with and without Drainage in the Treatment of Chronic Subdural Hematoma: A Preliminary Report. World Neurosurg 2011; 75:731-6; discussion 620-3. [DOI: 10.1016/j.wneu.2010.11.042] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2010] [Revised: 11/24/2010] [Accepted: 11/24/2010] [Indexed: 11/20/2022]
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Postoperative intracranial haemorrhage: a review. Neurosurg Rev 2011; 34:393-407. [DOI: 10.1007/s10143-010-0304-3] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2010] [Revised: 09/27/2010] [Accepted: 11/10/2010] [Indexed: 01/31/2023]
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Lega BC, Danish SF, Malhotra NR, Sonnad SS, Stein SC. Choosing the best operation for chronic subdural hematoma: a decision analysis. J Neurosurg 2010; 113:615-21. [PMID: 19877806 DOI: 10.3171/2009.9.jns08825] [Citation(s) in RCA: 111] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Chronic subdural hematoma (CSDH), a condition much more common in the elderly, presents an increasing challenge as the population ages. Treatment strategies for CSDH include bur-hole craniostomy (BHC), twist-drill craniostomy (TDC), and craniotomy. Decision analysis was used to organize existing data and develop recommendations for effective treatment. METHODS A Medline search was used to identify articles about treatment of CSDH. Direct assessment by health care professionals of the relative health impact of common complications and recurrences was used to generate utility values for treatment outcomes. Monte Carlo simulation and sensitivity analyses allowed comparisons across treatment strategies. A second simulation examined whether intraoperative irrigation or postoperative drainage affect the outcomes following BHC. RESULTS On a scale from 0 to 1, the utility of BHC was found to be 0.9608, compared with 0.9202 for TDC (p = 0.001) and 0.9169 for craniotomy (p = 0.006). Sensitivity analysis confirmed the robustness of these values. Craniotomy yielded fewer recurrences, but more frequent and more serious complications than did BHC. There were no significant differences for BHC with or without irrigation or postoperative drainage. CONCLUSIONS Bur-hole craniostomy is the most efficient choice for surgical drainage of uncomplicated CSDH. Bur-hole craniostomy balances a low recurrence rate with a low incidence of highly morbid complications. Decision analysis provides statistical and empirical guidance in the absence of well-controlled large trials and despite a confusing range of previously reported morbidity and recurrence.
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Affiliation(s)
- Bradley C Lega
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.
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Kurabe S, Ozawa T, Watanabe T, Aiba T. Efficacy and safety of postoperative early mobilization for chronic subdural hematoma in elderly patients. Acta Neurochir (Wien) 2010; 152:1171-4. [PMID: 20336332 DOI: 10.1007/s00701-010-0627-4] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2009] [Accepted: 03/02/2010] [Indexed: 11/29/2022]
Abstract
BACKGROUND The incidences of chronic subdural hematoma (CSDH) will probably increase with the aging of the population; thus, postoperative care of elderly CSDH patients may play a more important role in surgical management. The aim of this study was to evaluate the efficacy of and adverse effects after postoperative early mobilization (EM) for elderly CSDH patients. METHODS This is a single-institution historical control study. One hundred eighty-two patients with CSDH aged 65 years and older underwent one burr-hole surgery between 2001 and 2008. This institution has prospectively conducted an EM protocol after surgery since 2005. The emphasis of the EM was helping patients not only to an upright position but also to walk beginning the day of operation. The incidences of postoperative complications and recurrence of CSDH were compared between the EM group (n = 91; 76.5 +/- 6.5 years old) and a delayed mobilization (DM) group (n = 91; 77.9 +/- 7.5 years old). RESULTS Postoperative complications, such as pneumonia and urinary tract infection, was observed in 24 (26.4%) in the DM group and 11 (12.1%) in the EM group (p < 0.05). The rate of recurrence did not differ between the two groups (6.6% and 8.8%, respectively; p = 0.58). CONCLUSIONS The results suggest that EM after one burr-hole surgery prevents postoperative complications without increasing the risk of recurrence in CSDH patients > or =65 years of age.
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Affiliation(s)
- Satoshi Kurabe
- Department of Neurosurgery, Niigata Prefectural Shibata Hospital, 1-2-8 Honcho, Shibata, Niigata, 957-8588, Japan.
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Kim BG, Lee KS, Shim JJ, Yoon SM, Doh JW, Bae HG. What determines the laterality of the chronic subdural hematoma? J Korean Neurosurg Soc 2010; 47:424-7. [PMID: 20617086 DOI: 10.3340/jkns.2010.47.6.424] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2010] [Revised: 04/30/2010] [Accepted: 05/23/2010] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Chronic subdural hematomas (CSDH) are more common on the left hemisphere than on the right. We verified this left predilection of CSDH and tried to explain the reason for this discrepancy. METHODS We investigated the laterality of CSDH in 182 patients who were treated from January 2005 to December 2009. We examined the symmetry of the cranium and the location of the lesion. RESULTS CSDH was more common on the left-side. The cranium was symmetric in 63 patients, asymmetric in 119 patients. The asymmetric crania were flat on the right-side in 77 patients, on the left-side in 42 patients. The density of the CSDHs was hypodense in 29 patients, isodense 132 patients, and the others in 21 patients. Bilateral hematomas were more common in the hypodense group. In the right flat crania, the hematoma was more commonly located on the opposite side of the flat side. While in the left flat crania, the hematoma was more common on the same side. CONCLUSION CSDHs occurred more frequently on the left side. The anatomical asymmetry of the cranium influences the left predilection of CSDH.
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Affiliation(s)
- Byoung-Gu Kim
- Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
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Amirjamshidi A, Abouzari M, Eftekhar B, Rashidi A, Rezaii J, Esfandiari K, Shirani A, Asadollahi M, Aleali H. Outcomes and recurrence rates in chronic subdural haematoma. Br J Neurosurg 2009; 21:272-5. [PMID: 17612917 DOI: 10.1080/02688690701272232] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The object of this study was to determine the relationship between outcome (assessed by Glasgow Outcome Scale) and recurrence in chronic subdural haematoma (CSDH). Eighty-two consecutive patients who underwent surgery for CSDH were included in this study. The relationship between the following variables and CSDH recurrence was studied: sex; age; history of trauma; Glasgow Coma Scale (GCS) at the time of admission (stage 1: GCS>12, stage 2: GCS: 8 - 12, stage 3: GCS<8); interval between head injury (when a history of trauma was present) and surgery; presence of a midline shift on CT scans; presence of intracranial air 7 days after surgery; haematoma density; haematoma width; presence of brain atrophy; and Glasgow Outcome Scale (GOS, both quantitative and non-quantitative) at the time of discharge. Throughout the analysis, p<0.05 was considered statistically significant. The results showed lower GCS (p<0.001), higher GOS (p<0.001), presence of intracranial air 7 days after surgery (p=0.002), and a high density haematoma (p<0.001) were significantly associated with recurrence of CSDH. It was concluded that GOS is related with recurrence in CSDH.
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Affiliation(s)
- A Amirjamshidi
- Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Rughani AI, Holmes CE, Penar PL. A NOVEL ASSOCIATION BETWEEN A CHRONIC SUBDURAL HEMATOMA AND A FIBRINOLYTIC PATHWAY DEFECT. Neurosurgery 2009; 64:E1192; discussion E1192. [DOI: 10.1227/01.neu.0000345650.60160.07] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE
Chronic subdural hematoma (CSDH) is a common form of intracranial hemorrhage that is known to recur in up to one-fifth of treated patients. We present a patient with recurrent CSDH who was found to have a defect in the fibrinolytic pathway, which may be a novel explanation for recurrent CSDH. This defect, deficiency of plasminogen activator inhibitor type I (PAI-1), should be recognized as a possible cause of CSDH.
CLINICAL PRESENTATION
A 49-year-old man presented with a CSDH, which recurred each time after 2 initially-effective craniotomies.
INTERVENTION
A deficiency of PAI-1 was diagnosed after the second recurrence. We hypothesize that this defect in the fibrinolytic system contributed to the recurrent hematoma. Treatment with aminocaproic acid led to resolution of the CSDH.
CONCLUSION
PAI-1 deficiency should be considered in patients with recurrent CSDH that lack another compelling explanation, particularly in patients with a family history of bleeding diatheses. PAI-1 deficiency can be identified by measuring plasma levels and can be treated with an oral course of aminocaproic acid.
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Affiliation(s)
- Anand I. Rughani
- Division of Neurosurgery, University of Vermont, Burlington, Vermont
| | - Chris E. Holmes
- Division of Hematology and Oncology, University of Vermont, Burlington, Vermont
| | - Paul L. Penar
- Division of Neurosurgery, University of Vermont, Burlington, Vermont
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