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Yang L, Li Z, Dai X, Wang L, Wang X, Liu H. Nontraumatic subdural hematoma in patients on hemodialysis with end-stage kidney disease: a systematic review and pooled analysis. Front Neurol 2023; 14:1251652. [PMID: 37789893 PMCID: PMC10542405 DOI: 10.3389/fneur.2023.1251652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 09/05/2023] [Indexed: 10/05/2023] Open
Abstract
Background The original treatment may aggravate when hemodialysis (HD) patients have nontraumatic subdural hematoma (NSDH). End-stage kidney disease patients are at increased risk for NSDH, but its risk factors and outcomes are not sufficiently explored at present. Methods Electronic databases, including PubMed, EMBASE, and Web of Science were searched by using various combinations of the keywords "Hemodialysis," "Renal Insufficiency," "Extracorporeal Dialysis," "Subdural Hematoma," "Subdural Hemorrhage," "Subdural Hematomas," and "Subdural Hemorrhages" in accordance with the PRISMA guidelines. Sixteen papers were selected. Relevant patient data were extracted, aggregated, and analyzed. Results A total of 74 patients were analyzed, including 37 male, 26 female, and 11 with no gender data, with a mean age of 56 years (range, 16-81 years). There were 43 patients with hypertension, 36 patients with diabetes, 16 patients who used oral anticoagulants before dialysis, and 10 patients with atrial fibrillation. The diagnosis of subdural hematoma (SDH) was made by computed tomography (CT) (n = 51), carotid arteriography (n = 7), surgical exploration (n = 3), and autopsy (n = 2). Forty cases underwent surgical treatment, including craniotomy and burr hole (or twist drill) drainage. The 1 year mortality rate of NSDH was 45.9%. The mortality rate after conservative treatment (61.8%) was higher than that after surgical intervention (32.5%). The mortality rate of NSDH in dialysis patients with atrial fibrillation and in those who used oral anticoagulants before hemodialysis (HD) was 90 and 81%, respectively. Conclusion NSDH is rare in HD, and mortality is high if NSDH occurs in dialysis patients. Surgical intervention reduces the mortality from NSDH in patients on HD (p < 0.02). Patients with atrial fibrillation and those who were taking oral anticoagulants before dialysis have a higher NSDH mortality (p < 0.01).
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Affiliation(s)
- Liling Yang
- Department of Nephrology, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan, China
| | - Zongping Li
- Department of Neurosurgery, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, China
| | - Xiaoyu Dai
- Department of Nephrology, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan, China
| | - Lijun Wang
- Department of Nephrology, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan, China
| | - Xiaoyi Wang
- Department of Neurosurgery, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, China
| | - Hongyuan Liu
- Department of Neurosurgery, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, China
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Catapano JS, Nguyen CL, Wakim AA, Albuquerque FC, Ducruet AF. Middle Meningeal Artery Embolization for Chronic Subdural Hematoma. Front Neurol 2020; 11:557233. [PMID: 33192990 PMCID: PMC7606850 DOI: 10.3389/fneur.2020.557233] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 09/18/2020] [Indexed: 02/03/2023] Open
Abstract
Chronic subdural hematoma (cSDH) is a common disease process associated with significant morbidity that occurs most often in elderly patients. Asymptomatic patients are typically treated conservatively, with surgical intervention reserved for patients with symptomatic and/or large hematomas that cause brain compression. However, conservatively managed cSDH cases frequently progress, and surgical evacuation of cSDH is associated with high rates of complication and recurrence. Recently, successful treatment of cSDH via middle meningeal artery (MMA) embolization has been reported in small case series and case reports. This article reviews the existing literature on MMA embolization for cSDH and discusses the need for randomized control trials and/or large prospective studies to establish the efficacy of MMA embolization for this disease.
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Affiliation(s)
- Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Candice L Nguyen
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Andre A Wakim
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, United States
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, United States
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Fu S, Li F, Bie L. Drug therapy for chronic subdural hematoma: Bench to bedside. J Clin Neurosci 2018; 56:16-20. [DOI: 10.1016/j.jocn.2017.07.034] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 06/21/2017] [Accepted: 07/20/2017] [Indexed: 01/03/2023]
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Abstract
Surgery is the standard treatment for chronic subdural hematoma (CSDH), one of the common problems in neurosurgical practice. Although medical treatment was used by some authors and found some positive results, it is not accepted by many authors. The aim of this review is to give overall view of the medical management of CSDH. Action of various drugs in the pathophysiological cascade of formation of CSDH was depicted. The review of literature is done under three headings – the primary medical treatment of CSDH, adjuvant medical treatment with surgery, and the treatment of the recurrence. Various classifications of CSDH and the factors influencing the outcome of medical treatment are discussed. There is a role of medical treatment in a selected group of patients with CSDH. Well-designed, multicenter, randomized controlled trials are required to define the indications and standard protocols for the medical treatment of CSDH.
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Affiliation(s)
- Amit Kumar Thotakura
- Department of Neurosurgery, NRI Academy of Sciences, Guntur, Andhra Pradesh, India
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Emich S, Richling B, McCoy MR, Al-Schameri RA, Ling F, Sun L, Wang Y, Hitzl W. The efficacy of dexamethasone on reduction in the reoperation rate of chronic subdural hematoma--the DRESH study: straightforward study protocol for a randomized controlled trial. Trials 2014; 15:6. [PMID: 24393328 PMCID: PMC3891985 DOI: 10.1186/1745-6215-15-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Accepted: 12/12/2013] [Indexed: 11/15/2022] Open
Abstract
Background Chronic subdural hematoma (cSDH) is a common neurosurgical disease. It is often considered to be a rather benign entity. In spite of well established surgical procedures cSDH is complicated by a recurrence rate up to 30%. Since glucocorticoids have been used for treatment of cSDH in 1962 their role is still discussed controversially in lack of evident data. On the basis of the ascertained inflammation cycle in cSDH dexamethasone will be an ideal substance for a short lasting, concomitant treatment protocol. Objective: to test the efficacy of dexamethasone on reduction inthe reoperation rate of cSDH. Methods/Design The study is designed as a double-blind randomized placebo-controlled trial 820 patients who are operated for cSDH and from the age of 25 years are included after obtaining informed consent. They are randomized for administration of dexamethasone (16-16-12-12-8-4 mg/d) or placebo (maltodextrin) during the first 48 hours after surgery. The type I error is 5% and the type II error is 20%. The primary endpoint is the reoperation within 12 weeks postoperative. Discussion This study tests whether dexamethasone administered over 6 days is a safe and potent agent in relapse prevention for evacuated cSDH. Trial registration EudraCT 201100354442
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Affiliation(s)
- Stephan Emich
- Christian Doppler Klinik, PMU Salzburg, Universitätsklinik für Neurochirurgie, Ignaz Harrer Str, 79, 5020 Salzburg, Austria.
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Berghauser Pont LME, Dirven CMF, Dippel DWJ, Verweij BH, Dammers R. The role of corticosteroids in the management of chronic subdural hematoma: a systematic review. Eur J Neurol 2012; 19:1397-403. [DOI: 10.1111/j.1468-1331.2012.03768.x] [Citation(s) in RCA: 103] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2011] [Accepted: 04/24/2012] [Indexed: 11/27/2022]
Affiliation(s)
| | - C. M. F. Dirven
- Department of Neurosurgery; Erasmus MC; Rotterdam The Netherlands
| | - D. W. J. Dippel
- Department of Neurology; Erasmus MC; Rotterdam The Netherlands
| | - B. H. Verweij
- Department of Neurosurgery; Rudolf Magnus Institute of Neuroscience; University MC Utrecht; Utrecht The Netherlands
| | - R. Dammers
- Department of Neurosurgery; Erasmus MC; Rotterdam The Netherlands
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Delgado-López PD, Martín-Velasco V, Castilla-Díez JM, Rodríguez-Salazar A, Galacho-Harriero AM, Fernández-Arconada O. Dexamethasone treatment in chronic subdural haematoma. Neurocirugia (Astur) 2009; 20:346-59. [PMID: 19688136 DOI: 10.1016/s1130-1473(09)70154-x] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Neurosurgeons are familiar with chronic subdural haematoma (CSH), a well-known clinical entity, which is usually treated by some modality of trepanation. Despite the excellent outcomes obtained by surgery, complications may occur, some of which may be potentially severe or fatal. Furthermore, up to 25% recurrence rate is reported. The authors present a novel approach to the management of CSH based on the use of dexamethasone as the treatment of choice in the majority of cases. PATIENTS AND METHODS Medical records of 122 CSH patients were retrospectively reviewed. At admission, symptomatic patients were classified according to the Markwalder Grading Score (MGS). Those scoring MGS 1-2 were assigned to the Dexamethasone protocol (4 mg every 8h, re-evaluation after 48-72 h, slow tapering), and those scoring MGS 3-4 were, in general, assigned to the Surgical protocol (single frontal twistdrill drainage to a closed system, without irrigation). Patients were followed in the Outpatient Office with neurological assessment and serial CT scans. RESULTS. Between March 2001 and May 2006, 122 consecutive CSH patients (69% male, median aged of 78, range 25-97) were treated. Seventy-three percent of the patients exhibited some kind of neurological defect (MGS 2-3-4). Asymptomatic patients (MGS 0) were left untreated. Initial treatment assignment was: 101 dexamethasone, 15 subdural drain, 4 craneotomy and 2 untreated. Twenty-two patients on dexamethasone ultimately required surgical drain (21.8%). Favourable outcome (MGS 0-1-2) was obtained in 96% and 93.9% of those treated with dexamethasone and surgical drain, respectively. Median hospital stay was 6 days (range 1- 41) for the dexamethasone group and the whole series, and 8 days (range 5-48) for the surgical group. Overall mortality rate was 0.8% and re-admissions related to the haematoma reached 14.7% (all maintained or improved their MGS). Medical complications occurred in 34 patients (27.8%), mainly mild hyperglycemic impairments. Median outpatient follow up was 25 weeks (range 8-90), and two patients were lost. DISCUSSION The rationale for the use of dexamethasone in CSH lies in its anti-angiogenic properties over the subdural clot membrane, as it is derived from experimental studies and the very few clinical observations published. Surgical evacuation of CSH is known to achieve excellent results but no well-designed trials compare medical versus surgical therapies. The experience obtained from this series lets us formulate some clinical considerations: dexamethasone is a feasible treatment that positively compares to surgical drain (and avoided two thirds of operations); the natural history of CSH allows a 48-72 h dexamethasone trial without putting the patient at risk of irreversible deterioration; eliminates all morbidity related to surgery and recurrences; does not provoke significant morbidity itself; reduces hospital stay; does not preclude ulterior surgical procedures; it is well tolerated and understood by the patient and relatives and it probably reduces costs. The authors propose a protocol that does not intend to substitute surgery but to offer a safe and effective alternative. CONCLUSION Data obtained from this large retrospective series suggests that dexamethasone is a feasible and safe option in the management of CSH. In the author's experience dexamethasone was able to cure or improve two thirds of the patients. This fact should be confirmed by others in the future. The true effectiveness of the therapy as compared to surgical treatment could be ideally tested in a prospective randomized trial.
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Abuelo JG, Shemin D, Chazan JA. Acute Symptoms Produced by Hemodialysis: A Review of Their Causes and Associations. Semin Dial 2007. [DOI: 10.1111/j.1525-139x.1993.tb00257.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Elliott MJ, Zimmerman D, Holden RM. Warfarin anticoagulation in hemodialysis patients: a systematic review of bleeding rates. Am J Kidney Dis 2007; 50:433-40. [PMID: 17720522 DOI: 10.1053/j.ajkd.2007.06.017] [Citation(s) in RCA: 133] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2007] [Accepted: 06/15/2007] [Indexed: 11/11/2022]
Abstract
BACKGROUND Despite common use of warfarin, the bleeding risk associated with this treatment in hemodialysis (HD) patients is unknown. STUDY DESIGN Systematic review. SELECTION CRITERIA FOR STUDIES Inclusion criteria were case series, cohort studies, and randomized controlled trials in dialysis patients that examined the bleeding risk associated with warfarin use compared with no warfarin or subcutaneous heparin. Studies with fewer than 10 subjects, case reports, abstracts lacking complete data sets, review articles, and editorials were excluded. PREDICTOR Warfarin use compared with no warfarin or subcutaneous heparin. OUTCOMES Data for bleeding were reported as rates: number of bleeding episodes per number of patient-years of warfarin exposure or follow-up. RESULTS Of 79 articles and abstracts, 5 met inclusion criteria and 3 more could be added after investigators provided additional information. All studies were of HD patients, and 7 of 8 evaluated the use of warfarin for the prevention of HD access thrombosis. Intensity of anticoagulation varied. Meta-analysis was not possible because of study heterogeneity. Studies of full-intensity anticoagulation and the 1 randomized controlled trial of low-intensity anticoagulation showed major bleeding episode rates ranging from 0.1 to 0.54 events/patient-year of warfarin exposure. These rates are approximately twice as high as those of HD patients receiving either no warfarin or subcutaneous heparin. LIMITATIONS This review is based largely on data from observational studies in which bleeding rates may be confounded by comorbidity. Relatively small sample sizes may provide imprecise estimates of rates. CONCLUSION Low- and full-intensity anticoagulation use in HD patients is associated with a significant bleeding risk, which has to be balanced against any potential benefit of therapy. This has to be considered carefully when prescribing warfarin to HD patients.
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Affiliation(s)
- Meghan J Elliott
- Division of Nephrology, Queen's University, Kingston, Ontario, Canada
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Brouns R, De Deyn PP. Neurological complications in renal failure: a review. Clin Neurol Neurosurg 2005; 107:1-16. [PMID: 15567546 DOI: 10.1016/j.clineuro.2004.07.012] [Citation(s) in RCA: 237] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2004] [Revised: 07/27/2004] [Accepted: 07/27/2004] [Indexed: 02/08/2023]
Abstract
Neurological complications whether due to the uremic state or its treatment, contribute largely to the morbidity and mortality in patients with renal failure. Despite continuous therapeutic advances, many neurological complications of uremia, like uremic encephalopathy, atherosclerosis, neuropathy and myopathy fail to fully respond to dialysis. Moreover, dialytic therapy or kidney transplantation may even induce neurological complications. Dialysis can directly or indirectly be associated with dialysis dementia, dysequilibrium syndrome, aggravation of atherosclerosis, cerebrovascular accidents due to ultrafiltration-related arterial hypotension, hypertensive encephalopathy, Wernicke's encephalopathy, hemorrhagic stroke, subdural hematoma, osmotic myelinolysis, opportunistic infections, intracranial hypertension and mononeuropathy. Renal transplantation itself can give rise to acute femoral neuropathy, rejection encephalopathy and neuropathy in graft versus host disease. The use of immunosuppressive drugs after renal transplantation can cause encephalopathy, movement disorders, opportunistic infections, neoplasms, myopathy and progression of atherosclerosis. We address the clinical, pathophysiological and therapeutical aspects of both central and peripheral nervous system complications in uremia.
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Affiliation(s)
- R Brouns
- Department of Neurology and Memory Clinic, Middelheim General Hospital, Antwerp, Belgium
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Decaux O, Cador B, Dufour T, Jégo P, Cazalets C, Laurat E, Grosbois B. [Nonsurgical treatment of chronic subdural hematoma with steroids: two case reports]. Rev Med Interne 2002; 23:788-91. [PMID: 12378833 DOI: 10.1016/s0248-8663(02)00676-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Hemorrhages beneath the dura define a subdural hematoma. EXEGESIS The course of chronic subdural hematoma may be asymptomatic for many months before diagnosis. Recovery is observed in 80% of patients after surgery. We report two cases of chronic subdural hematoma successfully treated with steroids. CONCLUSION Steroids can be an alternative treatment of subdural hematoma, specially in elderly or alcoholic patients.
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Affiliation(s)
- O Decaux
- Service de médecine interne, hôpital Sud, 16, boulevard de Bulgarie, 35056 Rennes, France
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Liliang PC, Tsai YD, Liang CL, Lee TC, Chen HJ. Chronic subdural haematoma in young and extremely aged adults: a comparative study of two age groups. Injury 2002; 33:345-8. [PMID: 12091031 DOI: 10.1016/s0020-1383(02)00020-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
To compare the clinical presentation, etiological factors and the outcome of chronic subdural haematoma (CSDH) in young and old adults, a retrospective analysis was performed by differentiating young adults, age<40 years (n=24) versus extremely aged adults, age>75 years (n=51). The clinical data, computed tomography (CT) findings and surgical outcome were recorded for analysis. We observed certain characteristics particular to young CSDH patients, higher incidence of headache (P<0.001) and vomiting (P=0.009), the shorter duration from trauma to operation (P=0.018) and more severe traumatic episodes (P=0.001). The older patients had a higher frequency of mental change (P=0.006), motor deficits (P=0.014) and larger haematomas (P<0.001). The surgical complication rate was not statistically different between the two age groups. An understanding of the varied clinical presentation of CSDH is essential to stimulate clinical suspicion and prompt evaluation, particularly for the differences between young and extremely aged patients.
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Affiliation(s)
- Po-Chou Liliang
- Department of Neurosurgery, Chang Gung Memorial Hospital, Kaohsiung Medical Center, 123 Tapei Road, Niaosung Hsiang, Kaohsiung Hsien, Taiwan
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Parlato C, Guarracino A, Moraci A. Spontaneous resolution of chronic subdural hematoma. SURGICAL NEUROLOGY 2000; 53:312-5; discussion 315-7. [PMID: 10825513 DOI: 10.1016/s0090-3019(00)00200-7] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Spontaneous resolution of chronic subdural hematoma has rarely been reported in the literature, and its mechanism has not been fully investigated. Response to surgery has been very satisfactory; in fact, this is generally considered the treatment of choice. METHODS From a series of 24 cases of chronic subdural hematomas, we observed five patients between 1996 to 1998. These patients showed headache and decrease of cognitive level, 4-5 weeks after minor head injury. Neurologic evaluation revealed only worsening of mental function according to Mini Mental State Examination (MMSE). Computed tomography (CT) scans showed brain atrophy and chronic subdural hematoma without increased intracranial pressure. These patients were treated by clinical observation and serial cerebral CT scans. RESULTS After 7 to 10 days, all patients showed improvement of clinical signs. After 30 to 45 days, radiological disappearance or marked reduction in size of the hematoma and complete clinical recovery were obtained. No neurological deficits and no recurrences have been observed during follow-up (3 months to 2 years). CONCLUSIONS We believe that age greater than 70 years, decreased cognitive level (MMSE = 21), brain atrophy, and absence of increase of intracranial pressure are clinical and radiological signs that allow one to choose conservative treatment.
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Affiliation(s)
- C Parlato
- Institute of Neurosurgery, Second University of Naples, Viale Colli Aminei 2, 80131, Naples, Italy
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Wong CW. Criteria for conservative treatment of supratentorial acute subdural haematomas. Acta Neurochir (Wien) 1995; 135:38-43. [PMID: 8748790 DOI: 10.1007/bf02307412] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Without mortality, 31 patients underwent conservative treatment for traumatic supratentorial acute subdural haematoma (SDH). Later on six of them had the haematoma surgically evacuated mainly because of a deterioration of the Glasgow Coma Scale (GCS) scores. It was found that patients with a midline shift of less than 10 mm on the computed tomography (CT) scans and with a GCS score of 15 initially might be treated conservatively under close observation, reserving urgent craniotomy and evacuation of the SDH for those with deteriorating neurological conditions. A smaller degree of midline shift was tolerated by patients with an GCS score of less than 15: a shift of more than 5 mm on the initial CT scans predicted an exhaustion of the cerebral compensatory mechanism within 3 days of injury. In such cases the GCS score worsened, and surgical evacuation of the SDH became necessary. A total hospital stay of 6 to 7 days may suffice for those who have become fully conscious. Repeat CT studies before discharge should be done and a close follow-up during the first 3 to 4 weeks is advisable.
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Affiliation(s)
- C W Wong
- Department of Surgery, Chang Gung Memorial Hospital and Medical College, Taipei, Taiwan, Republic of China
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