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Borni M, Kolsi F, Taallah M, Boudawara MZ. A chronic subdural hematoma complicating an arachnoid cyst in a juvenile boxer: a rare case report with comprehensive literature review. Ann Med Surg (Lond) 2023; 85:5756-5760. [PMID: 37915627 PMCID: PMC10617852 DOI: 10.1097/ms9.0000000000001338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 09/11/2023] [Indexed: 11/03/2023] Open
Abstract
Introduction and importance Arachnoid cyst (AC) is the most frequently founded lesion reported in adolescent patients suffering from chronic subdural haematoma (CSDH). Association between these two distinct clinical entities is known for a long time. However, in the literature there are numerous clinical cases that reflect this relationship and few large series that analyze them in detail. Paediatric population is more rarely affected with this association. Case presentation The authors report the case of AC of incidental discovery complicated with CSDH in 15-year-old male recreational boxer presented with progressive onset of holocranial drug-resistant throbbing headache with favourable clinical course after conservative treatment. Clinical discussion ACs are a well-known predisposing cause for CSDH after head trauma. In all cases of CSDH in children, the diagnosis of ruptured AC should be considered. Rupture may be spontaneous or following even mild head trauma with rupture of bridging veins causing subdural bleeding as it was seen in our patient who was practicing a full-contact free-sparring sport like boxing sustaining repeated and direct mild head traumas. MRI is recommended to detect small cysts in adolescents with CSDH. The management of these patients remains controversial. Conclusion This is a rare reported case of CSDH complicating an AC in a juvenile recreational male boxer. This association remains extremely rare in children and adolescents, as evidenced by the rare cases reported in the literature.
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Affiliation(s)
- Mehdi Borni
- Department of Neurosurgery, UHC Habib Bourguiba, Sfax, Tunisia
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Holl DC, Volovici V, Dirven CMF, van Kooten F, Miah IP, Jellema K, Peul WC, van der Gaag NA, Kho KH, den Hertog HM, Dammers R, Lingsma HF. Corticosteroid treatment compared with surgery in chronic subdural hematoma: a systematic review and meta-analysis. Acta Neurochir (Wien) 2019; 161:1231-1242. [PMID: 30972566 DOI: 10.1007/s00701-019-03881-w] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 03/20/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND There is an ongoing debate on the role of corticosteroids in the treatment of chronic subdural hematoma (CSDH). This study aims to evaluate the effectiveness of corticosteroids for the treatment of CSDH compared to surgery. METHOD A systematic search was performed in relevant databases up to January 2019 to identify RCTs or observational studies that compared at least two of three treatment modalities: the use of corticosteroids as a monotherapy (C), corticosteroids as an adjunct to surgery (CS), and surgery alone (S). Outcome measures were good neurological outcome, need for reintervention, mortality, and complications. Effect estimates were pooled and presented as relative risk (RR) with 95% confidence interval (95%CI). RESULTS Of 796 initially identified studies, 7 were included in the meta-analysis. Risk of bias was generally high. There were no differences in good neurological outcome between treatment modalities. The need for reintervention varied between 4 and 58% in C, 4-12% in CS, and 7-26% in S. The need for reintervention was lower in CS compared with C (RR 3.34 [95% CI 1.53-7.29]; p < 0.01) and lower in CS compared with S (RR 0.44 [95% CI 0.27-0.72]; p < 0.01). Mortality varied between 0 and 4% in C, 0-13% in CS, and 0-44% in S. Mortality was lower in CS compared with S (RR 0.39 [95% CI 0.25-0.63]; p < 0.01). There were no differences in complications between treatment modalities. CONCLUSIONS This meta-analysis suggests that the addition of corticosteroids to surgery might be effective in the treatment of CSDH. However, the results must be interpreted with caution in light of the serious risk of bias of the included studies. This study stresses the need for large randomized trials to investigate the use of corticosteroids in the management of CSDH.
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Affiliation(s)
- Dana C Holl
- Department of Neurosurgery, Erasmus MC Stroke Centre, Erasmus Medical Centre, 2040, 3000 CA Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands.
| | - Victor Volovici
- Department of Neurosurgery, Erasmus MC Stroke Centre, Erasmus Medical Centre, 2040, 3000 CA Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
- Department of Public Health and Medical Decision Making, Erasmus MC, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Clemens M F Dirven
- Department of Neurosurgery, Erasmus MC Stroke Centre, Erasmus Medical Centre, 2040, 3000 CA Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Fop van Kooten
- Department of Neurology, Erasmus MC Stroke Centre, Erasmus Medical Centre, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Ishita P Miah
- Department of Neurology, Haaglanden Medical Centre, Postbus 432, 2501 CK, The Hague, The Netherlands
| | - Korné Jellema
- Department of Neurology, Haaglanden Medical Centre, Postbus 432, 2501 CK, The Hague, The Netherlands
| | - Wilco C Peul
- Department of Neurosurgery, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Niels A van der Gaag
- Department of Neurosurgery, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Haaglanden MC and Haga Teaching Hospital, Postbus 432, 2501 CK, The Hague, The Netherlands
| | - Kuan H Kho
- Department of Neurosurgery, Medisch Spectrum Twente, Koningsplein 1, 7512 KZ, Enschede, The Netherlands
| | - Heleen M den Hertog
- Department of Neurology, Isala Hospital Zwolle, Dokter van Heesweg 2, 8025 AB, Zwolle, The Netherlands
| | - Ruben Dammers
- Department of Neurosurgery, Erasmus MC Stroke Centre, Erasmus Medical Centre, 2040, 3000 CA Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Hester F Lingsma
- Department of Public Health and Medical Decision Making, Erasmus MC, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
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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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Castro-Rodríguez C, Román-Pena P, Arán-Echabe E, Gelabert-González M. [Chronic subdural haematomas in very elderly patients]. Rev Esp Geriatr Gerontol 2016; 51:309-316. [PMID: 27345661 DOI: 10.1016/j.regg.2016.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 05/09/2016] [Accepted: 05/13/2016] [Indexed: 06/06/2023]
Abstract
INTRODUCTION Chronic subdural haematoma (CSDH) is one of the most common neurosurgical conditions and is especially prevalent among elderly individuals. The objective of this study was to analyse the demographic, clinical and radiological findings, and surgical outcomes in a series of chronic subdural haematoma in patients older than 85 years. PATIENTS AND METHODS A review was carried out on all patients over 85 years with CSDH treated in our neurosurgical service from April 1986 to November 2015. A record was made of the baseline patient characteristics (age, sex, comorbidities, known risk factors, imaging characteristics, and number of burr-holes) and surgical outcomes (complications, especially recurrences and mortality). An analysis was carried out on the special characteristics of these patients, as well as the relationships between gender, clinical grade, anti-platelet or anticoagulant therapy, internal architecture of the haematoma, and midline shift, with mortality and recurrence of the haematoma. RESULTS A total of 200 patients were included, with a mean age of 88.5 (range 85-104) years, and the male: female sex ratio was 1:1.1. History of injury was reported in 114 (57%) cases. Anti-platelet or anticoagulant therapy was being used by 71 (35.5%) patients. On admission, 114 patients (57%) were in satisfactory condition (Markwalder grades 0-2). The main symptom was behavioural disturbance in 82 (41%) cases. CSDH was left-sided in 89 (44.5%) patients, right-sided in 78 (39%) cases (39%), and bilateral in the remaining 33 (16.5%) cases). Postoperative complications were observed in 59 cases (29 recurrences). Preoperative Markwalder grade correlated significantly with recurrence rate and mortality (P<.0001). CONCLUSIONS CSDH was a very common disease in very elderly patients. Behavioural disturbance and neurological deficits are the most common first symptom. Preoperative neurological status at admission is the most important factor in recurrences and mortality.
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Affiliation(s)
| | - Paula Román-Pena
- Departamento de Cirugía, Universidad de Santiago de Compostela, Santiago de Compostela, España; Servicio de Neurocirugía, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, España
| | - Eduardo Arán-Echabe
- Departamento de Cirugía, Universidad de Santiago de Compostela, Santiago de Compostela, España; Servicio de Neurocirugía, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, España
| | - Miguel Gelabert-González
- Departamento de Cirugía, Universidad de Santiago de Compostela, Santiago de Compostela, España; Servicio de Neurocirugía, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, España.
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[Bilateral chronic subdural haematoma: Analysis of a series of 190 patients]. Neurocirugia (Astur) 2015; 27:103-11. [PMID: 26589663 DOI: 10.1016/j.neucir.2015.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Revised: 07/21/2015] [Accepted: 07/23/2015] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The aim of this study is to analyse the clinical findings and surgical results in a series of patients with bilateral chronic subdural haematoma (BCSDH), and compare the results with a series of patients treated for unilateral chronic subdural haematoma (UCSDH). PATIENTS AND METHODS A retrospective study was performed on 1523 patients diagnosed and surgically treated for chronic subdural haematoma over a period of 30 years. Patients were divided into 2 groups: The study group consisting of 190 patients operated on for a BCSDH and the control group consisting of patients operated on for an UCSDH (1333 cases). RESULTS The patient series included 126 males (66.3%) and 64 females (33.7%), with a mean age at diagnosis of 74.8±10.2. The control group consisted of 870 males (65.2%) and 463 women (34.8%), with a mean age of 73.2±12.1. The most common presenting symptoms was cognitive impairment in 63 patients (33.2%) with BCSDH and 416 (29.5%) with UCSDH. Recurrence rates were 9.4% (18 patients) and 5.7% (77 patients) in unilateral and bilateral haematomas, respectively. The mortality was 10 patients (5.2%) with BCSDH and 55(4%) with UCSDH. Factors significantly related to recurrence in the univariate analysis were being male (P=.040), anticoagulant/antiplatelet therapy (P=.032), and poor neurological status at admission (P=.039). CONCLUSIONS This study indicates that BCSDH is more frequent in males, and the most common presentation is headache. The most important factors influencing recurrences are being male, intake of anticoagulant-antiaggregant drugs, and worse clinical status at admission.
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Gelabert-González M, Rico-Cotelo M, Arán-Echabe E. Burr hole is not burr hole. Acta Neurochir (Wien) 2015; 157:661-2. [PMID: 25663142 DOI: 10.1007/s00701-015-2365-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 01/26/2015] [Indexed: 10/24/2022]
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Gelabert-González M, Rico-Cotelo M, Arán-Echabe E. [Chronic subdural hematoma]. Med Clin (Barc) 2015; 144:514-9. [PMID: 25746613 DOI: 10.1016/j.medcli.2015.01.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Accepted: 01/19/2015] [Indexed: 01/01/2023]
Affiliation(s)
- Miguel Gelabert-González
- Servicio de Neurocirugía, Departamento de Cirugía, Hospital Clínico Universitario de Santiago, Universidad de Santiago de Compostela, Santiago de Compostela, A Coruña, España.
| | - María Rico-Cotelo
- Servicio de Neurocirugía, Departamento de Cirugía, Hospital Clínico Universitario de Santiago, Universidad de Santiago de Compostela, Santiago de Compostela, A Coruña, España
| | - Eduardo Arán-Echabe
- Servicio de Neurocirugía, Departamento de Cirugía, Hospital Clínico Universitario de Santiago, Universidad de Santiago de Compostela, Santiago de Compostela, A Coruña, España
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Gelabert-González M, Arán-Echabe E. Mini-craniotomy and chronic subdural hematoma. Acta Neurochir (Wien) 2014; 156:1969-70. [PMID: 24770731 DOI: 10.1007/s00701-014-2094-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 04/01/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Miguel Gelabert-González
- Department of Surgery, University of Santiago de Compostela. Clinic Hospital of Santiago de Compostela, A Choupana, 15706, Santiago de Compostela, Spain,
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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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Cheng SY, Chang CK, Chen SJ, Lin JF, Tsai CC. Chronic Subdural Hematoma in Elderly Taiwan Patients: A Retrospective Analysis of 342 Surgical Cases. INT J GERONTOL 2014. [DOI: 10.1016/j.ijge.2014.01.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Stippler M, Ramirez P, Berti A, MacIndoe C, Villalobos N, Murray-Krezan C. Chronic subdural hematoma patients aged 90 years and older. Neurol Res 2013; 35:243-6. [DOI: 10.1179/1743132813y.0000000163] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Affiliation(s)
- Martina Stippler
- Department of NeurosurgeryUniversity of New Mexico, Albuquerque, NM, USA
| | - Pedro Ramirez
- Department of NeurosurgeryUniversity of New Mexico, Albuquerque, NM, USA
| | - Aldo Berti
- Department of NeurosurgeryUniversity of New Mexico, Albuquerque, NM, USA
| | - Chamisa MacIndoe
- Department of NeurosurgeryUniversity of New Mexico, Albuquerque, NM, USA
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Gelabert-González M, Aran-Echabe E. Chronic subdural hematomas and the elderly. Surg Neurol Int 2013; 4:83. [PMID: 23869283 PMCID: PMC3709280 DOI: 10.4103/2152-7806.113649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2013] [Accepted: 05/16/2013] [Indexed: 11/04/2022] Open
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Gelabert-Gonzalez M, Aran-Echabe E. Outcomes in octogenarians with subdural hematomas. Clin Neurol Neurosurg 2013; 115:1924-5. [PMID: 23791430 DOI: 10.1016/j.clineuro.2013.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Revised: 04/09/2013] [Accepted: 05/05/2013] [Indexed: 11/19/2022]
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Svoboda T, Ramsay JT. High rates of head injury among homeless and low-income housed men: a retrospective cohort study. Emerg Med J 2013; 31:571-575. [DOI: 10.1136/emermed-2012-201761] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2012] [Revised: 03/28/2013] [Accepted: 04/01/2013] [Indexed: 11/03/2022]
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Gelabert-González M, Frieiro-Dantas C, Serramito-García R, Díaz-Cabanas L, Aran-Echabe E, Rico-Cotelo M, García-Allut A. [Chronic subdural hematoma in young patients]. Neurocirugia (Astur) 2012; 24:63-9. [PMID: 23158924 DOI: 10.1016/j.neucir.2012.08.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2012] [Revised: 08/03/2012] [Accepted: 08/03/2012] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The objective of this study was to analyse demographic, clinical and radiological findings and surgical results in a series of chronic subdural haematomas (CSDH) in young adult patients. PATIENTS AND METHODS This retrospective study included 42 patients under 40 years of age who were diagnosed and surgically treated for a CSDH during a 30-year period (1982-2011). RESULTS Of the 42 cases analysed, 32 were males and 10 were females, and the mean age at diagnosis was 29.3±8.9 years (range: 4 to 39 years). The mean interval from trauma to appearance of clinical symptoms was 33.4±9.7 days (range: 19 to 95 days). The main symptoms were headache (59.5%) and seizures (21.4%), and the most frequent predisposing factors were ventriculoperitoneal shunting in 5 (11.9%) patients and haematological disorders in another 5 (11.9%) cases. CSDH was right-sided in 21 cases (50%), left-sided in 19 cases (45.3%) and bilateral in the remaining 2 patients (4.7%). Postoperative complications occurred in 2 patients (1 recurrence and 1 acute subdural haematoma). CONCLUSIONS CSDH is a rare pathology during the first decades of life. It mainly affects males and headache is usually the first symptom. Prognosis is good in young patients, since postoperative complications and recurrences are less frequent at this age than in older populations.
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MESH Headings
- Adolescent
- Adult
- Child
- Child, Preschool
- Craniotomy
- Dominance, Cerebral
- Female
- Headache/etiology
- Hematoma, Subdural, Chronic/complications
- Hematoma, Subdural, Chronic/diagnostic imaging
- Hematoma, Subdural, Chronic/epidemiology
- Hematoma, Subdural, Chronic/surgery
- Humans
- Male
- Postoperative Complications/etiology
- Retrospective Studies
- Seizures/etiology
- Tomography, X-Ray Computed
- Trephining
- Ventriculoperitoneal Shunt/adverse effects
- Young Adult
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Affiliation(s)
- Miguel Gelabert-González
- Servicio de Neurocirugía, Departamento de Cirugía, Hospital Clínico Universitario de Santiago, Universidad de Santiago de Compostela, Santiago, La Coruña, España.
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Gelabert González M, Castro Bouzas D, Serramito García R. Tratamiento mínimamente invasivo del hematoma subdural crónico del adulto. Resultados en 116 pacientes. NEUROLOGÍA (ENGLISH EDITION) 2012. [DOI: 10.1016/j.nrleng.2011.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Gelabert González M, Castro Bouzas D, Serramito García R. [Minimally invasive treatment of chronic subdural haematoma in adults: results in 116 patients]. Neurologia 2012; 27:311-2; author reply 312. [PMID: 22377536 DOI: 10.1016/j.nrl.2011.10.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2011] [Accepted: 10/30/2011] [Indexed: 10/28/2022] Open
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Gelabert-González M, Serramito-Garcia R. Chronic subdural hematoma. J Neurosurg 2011; 114:887-8; author reply 888. [PMID: 21275562 DOI: 10.3171/2010.11.jns101830] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Gelabert-González M, Castro-Bouzas D, Arcos-Algaba A, Santín-Amo J, Díaz-Cabanas L, Serramito-García R, Arán-Echabe E, Prieto-González A, García-Allut A. Hematoma subdural crónico asociado a quiste aracnoideo. Presentación de 12 casos. Neurocirugia (Astur) 2010. [DOI: 10.1016/s1130-1473(10)70079-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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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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Gelabert-González M, Iglesias-Pais M, García-Allut A, Martínez-Rumbo R. Chronic subdural haematoma: surgical treatment and outcome in 1000 cases. Clin Neurol Neurosurg 2005; 107:223-9. [PMID: 15823679 DOI: 10.1016/j.clineuro.2004.09.015] [Citation(s) in RCA: 225] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2004] [Revised: 08/16/2004] [Accepted: 09/14/2004] [Indexed: 11/23/2022]
Abstract
Chronic subdural haematoma (CSDH) is one of the most common clinical entities in daily neurosurgical practice. To evaluate the clinical features, computed tomography findings, surgical results, and complications our series was statistically analysed to elucidate the factors affecting the post-operative outcome. A retrospective study (1980-2002) of the records of 1000 patients harbouring 1097 chronic subdural haematoma treated with burr-hole craniotomy with closed-system drainage was carried out. The series included 628 males and 372 females, age range 12-100 years, mean age 72.7+/-11.4 years. The mean interval from trauma to appearance of clinical symptoms was 49.1+/-7.4 days (15-751). The principal symptom was headache (29.7%) in the over 70s, and behavioural disturbance (33.8%) in the under 70s. The CSDH was right sided in 432 patients, left sided in 471, and bilateral in the remaining 97 cases. Post-operative complications occurred in 196 patients and 21 patients died in hospital. Poor prognosis was related to patient's age (>70) and clinical grade on admission (grades 0-2 versus grades 3-4).
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Affiliation(s)
- Miguel Gelabert-González
- Neurosurgical Service, Department of Surgery, Clinic Hospital of Santiago, University of Santiago de Compostela, La Choupana, 15706 Santiago de Compostela, Spain.
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