Drug treatment of chronic subdural hematoma

Efficacy and Safety of Atorvastatin for Chronic Subdural Hematoma: An Updated Systematic Review and Meta-Analysis

BACKGROUND

Chronic subdural hematoma (CSDH) is a common neurological condition, especially in the elderly population. Atorvastatin has shown the potential to reduce the recurrence of CSDH and improve overall outcomes. New studies have emerged since the last meta-analysis, increasing the sample size and the variety of outcomes analyzed.

METHODS

We searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials for studies comparing the use of atorvastatin in CSDH patients with a control group or placebo. The primary outcome was the recurrence of CSDH. Secondary outcomes of interest were hematoma volume, composite adverse effects, mortality, and neurological function, measured by the Glasgow Outcome Scale and Barthel index for activities of daily living.

RESULTS

Seven studies, of which 2 were randomized controlled trials, were included, containing 1192 patients. Overall recurrence significantly decreased compared to the control group (risk ratio [RR] 0.46; 95% confidence interval [CI] 0.25-0.83; P=0.009). The benefits of atorvastatin were sustained in the subgroup analysis of patients who underwent initial conservative therapy (RR 0.40; 95% CI 0.22-0.70; P=0.001). However, there was no significant difference when atorvastatin was combined with surgical intervention (RR 0.53; 95% CI 0.21-1.32; P=0.17). Adverse effects were not increased by atorvastatin (RR 0.82; 95% CI 0.51-1.34; P=0.44).

CONCLUSIONS

Atorvastatin might be beneficial in reducing CSDH recurrence, especially in conservative treatment patients. Atorvastatin was not significantly associated with adverse effects. Larger, higher-quality randomized studies are needed to adequately evaluate the efficacy, safety, and optimal dose of atorvastatin in CSDH patients.

Effectiveness of traditional herbal Kampo medicine Goreisan on chronic subdural hematoma recurrence: a meta-analysis

Objectives: Our objective was to compare the effectiveness of Traditional Chinese herbal Kampo medicine Goreisan in improving recurrence in patients with chronic subdural hematoma (CSDH). Methods: Eligible randomized controlled trials prospective trials, and retrospective cohort studies were systematically identified through searches of PubMed, Cochrane Library, and CNKI from inception to March 2024. Following the application of predetermined inclusion and exclusion criteria to screen the available studies, main outcome measures were rigorously extracted. RevMan v5.4 software was utilized to evaluate the overall recurrence rate, employing a random-effects model to calculate pooled odds ratios with the Mantel-Haenszel estimation method. Inter-study heterogeneity was assessed using the Cochran Q (Chi-square) test and I2 statistics. Funnel plots were used to evaluate publication bias. Results: Among the 48 articles initially screened for citation, eight were ultimately selected for inclusion in the study. The results of our network meta-analysis indicate that patients with newly diagnosed Chronic subdural hematoma experienced a significantly reduced recurrence rate when treated with Goreisan compared to standard neurosurgical treatment (OR: 0.72; 95% CI 0.61-0.86; p = 0.00003). There was no statistically significant difference in the incidence rates of complications, including general fatigue, allergic reactions, hepatic dysfunction, and interstitial pneumonia (OR: 7.21; 95% CI 0.37-141.29; p = 0.19). Conclusion: Traditional medicine Goreisan was effective in reducing CDSH recurrence rates. For clinical treatment, it provides a high level of evidence-based medicine. It is also necessary to conduct multicenter randomized controlled trials with dose adjustments to determine whether Goreisan interventions improve neurological function or prognosis.

Preoperative Fibrinogen Levels and Function as Predictive Factors for Acute Bleeding in the Hematoma Cavity After Burr Hole Drainage in Patients with CSDH

OBJECTIVE

Burr hole drainage (BHD) is the primary surgical intervention for managing chronic subdural hematoma (CSDH). However, it can lead to postoperative complications such as acute bleeding within the hematoma cavity and hematoma recurrence. The objective of this study is to identify the risk factors for these complications and develop a predictive model for acute hematoma cavity bleeding after BHD in patients with CSDH.

METHODS

This study presents a retrospective cohort investigation conducted at a single center. The clinical dataset of 308 CSDH patients who underwent BHD at a hospital from 2016 to 2022 was analyzed to develop and assess a prognostic model.

RESULTS

The nonbleeding group exhibited a significant correlation between fibrinogen (FIB) and thrombin time (TT), whereas no correlation was observed in the bleeding group. Notably, both FIB and TT were identified as risk factors for postoperative acute bleeding within the hematoma cavity. We developed a prognostic model to predict the occurrence of postoperative acute bleeding within the hematoma cavity after BHD in patients with CSDH. The model incorporated FIB, TT, coronary artery disease, and Glasgow Coma Scale scores. The model exhibited good discrimination (area under the curve: 0.725) and calibration (Hosmer-Leeshawn goodness of fit test: P > 0.1). Furthermore, decision curve analysis demonstrated the potential clinical benefit of implementing this prediction model.

CONCLUSIONS

The predictive model developed in this study can forecast the risk of postoperative acute bleeding within the hematoma cavity, thus aiding clinicians in selecting the optimal treatment approach for patients with CSDH.

Potential impact of high-density lipoprotein cholesterol in the postoperative outcomes of chronic subdural hematoma patients: multi-institutional study in Korea

BACKGROUND

Chronic subdural hematoma (CSDH) is a common clinical situation in neurosurgical practice, but the optimal treatment option is controversial. This study aimed to evaluate the effect of cholesterol-lowering medications on and how they affected the prognoses of CSDH patients.

METHODS

In this multi-institutional observational study performed in Korea, data from recently treated CSDH patients were gathered from 5 hospitals. A total of 462 patients were collected from March 2010 to June 2021. Patient clinical characteristics, history of underlying diseases and their treatments, radiologic features, and surgical outcomes were analyzed.

RESULTS

Seventy-five patients experienced recurrences, and 62 had reoperations after the initial burr hole surgery. Among these, 15 patients with recurrences and 12 with reoperations were taking cholesterol-lowering medications. However, the use of medications did not significantly affect recurrence or reoperation rates (P = 0.350, P = 0.336, respectively). When analyzed by type of medication, no clinically relevant differences in total cholesterol (TC), triglyceride (TG), or low-density lipoprotein cholesterol (LDL-C) levels were identified. The combination of a statin drug and ezetimibe significantly elevated high-density lipoprotein cholesterol (HDL-C) levels (P = 0.004). TC, LDL-C, and TG levels did not significantly affect patient prognoses. However, HDL-C levels and recurrence (odds ratio (OR) = 0.96; 95% confidence interval (CI): 0.94-0.99; p = 0.010) were negatively correlated. An HDL-C level of 42.50 mg/dL was identified as the threshold for recurrence and reoperation.

CONCLUSIONS

In this study, using cholesterol-lowering medications did not significantly impact the prognosis of patients who underwent surgical management for a chronic subdural hematoma. However, the findings showed that the higher the HDL-C level, the lower the probability of recurrence and reoperation.

Time and Influencing Factors to Chronic Subdural Hematoma Resolution After Middle Meningeal Artery Embolization

OBJECTIVE

We sought to describe the resolution time of chronic subdural hematoma (CSDH) after middle meningeal artery embolization (MMAE) and potential variables that may affect hematoma resolution.

METHODS

A retrospective analysis was performed on CSDH patients between December 2018 and December 2021. Patient characteristics, radiologic manifestations, and data of hematoma resolution were recorded. Univariate and multivariate analyses were conducted to identify predictors of CSDH resolution time.

RESULTS

A total of 53 patients were enrolled including 53 hematomas. Only 1 participant relapsed and did not require surgical evacuation. Hematoma resolution was observed in 27 (50.9%) at 4 months and 48 (90.6%) cases at the last radiologic follow-up. The median MMAE-to-resolution time was 19 weeks (interquartile range: 8-24). The burr-hole irrigation + MMAE group showed faster hematoma resolution than MMAE alone during early follow-up periods, but no significant difference was found at 6 months. Increased thickness of residual hematoma, excessive postoperative midline shift, high-density hematoma, mixed-density hematoma, separated hematoma, and anticoagulant or antiplatelet agents used were predictive of nonresolution at 4 months as determined by univariate analysis, whereas anticoagulant or antiplatelet agents used and high-density hematoma were not significant on multivariate analysis. No significant association was noted between hematoma resolution and comorbidities or other hematoma radiologic features.

CONCLUSIONS

MMAE is an effective and minimally invasive treatment for CSDH with a lower recurrence rate. The median resolution time of CSDH following MMAE was 19 weeks (interquartile range: 8-24). Burr-hole irrigation contributed to early hematoma resolution but had no significant effect at 6 months. In addition, residual hematoma thickness, postoperative midline shift, and specific type of hematoma were associated with delayed hematoma resolution at 4 months.

Renin-angiotensin-aldosterone system inhibitors as a risk factor for chronic subdural hematoma recurrence: A matter of debate

OBJECTIVES

Chronic subdural hematoma (cSDH) is a common central nervous system condition. Recent reports indicate that cSDH affects long-term prognosis; however, its definitive risk factors remain unknown. An antihypertensive drug, renin-angiotensin-aldosterone system inhibitors (RAASi), can affect vascular permeability and cell proliferation processes, which may suppress the recurrence of cSDH. However, several studies have reported negative results to this effect. Therefore, we aimed to evaluate antihypertensive drugs, including RAASi, as risk factors for recurrent cSDH.

MATERIALS AND METHODS

A total of 203 consecutive cases of surgically treated cSDH were retrospectively reviewed. Clinical and radiological parameters were compared between the groups with and without cSDH recurrence to identify risk factors.

RESULTS

Of the included cases, 68 (33.5%) used RAASi and 37 (18.2%) developed recurrence within 60 days of surgery. In the multiple logistic regression analysis adjusted by composite risk score, the odds ratios (95% confidence interval) of RAASi, calcium channel blockers, diuretics, β and α blockers, for the recurrent risk of cSDH after surgery were 2.49 (1.16, 5.42), 1.79 (0.84, 3.82), 1.83 (0.62, 4.87), 0.90 (0.28, 2.44), and 0.96 (0.21, 3.20), respectively. The Cox proportional hazard model also demonstrated that RAASi-use was an independent risk factor for cSDH recurrence.

CONCLUSIONS

Present series suggests RAASi-use as a risk factor for cSDH recurrence, although the role of RAASi-use in cSDH remains debatable. Further studies for deeper understanding of the microenvironment of hematoma and the surroundings are preferable. (235 words).

Craniocervical Manual Lymphatic Drainage Increases the Efficiency of Atorvastatin-Based Treatment of Chronic Subdural Hematoma

The objective of this study is to explore whether craniocervical manual lymphatic drainage (cMLD) can promote hematoma absorption and increase the efficiency of atorvastatin-based conservative treatment in chronic subdural hematoma (CSDH) patients. All CSDH patients treated with atorvastatin-based therapy between October 2020 and February 2022 in our department were retrospectively screened for enrollment. The patients were divided into the control and cMLD groups according to whether cMLD was performed. Head CT or MR images in both groups were obtained before the treatment and 2 weeks and 4 weeks after the treatment. MR images of the deep cervical lymphatic nodes (dCLNs) in 23 patients were obtained in the cMLD group before and approximately 2 weeks after treatment. The volumes of the dCLNs and hematoma were calculated. The primary outcomes are the differences in hematoma volume reduction after 4 weeks of treatment. The secondary outcomes were (1) the differences in hematoma volume reduction between the patients in these two groups in the 2nd week, (2) the dCLN volume change in the cMLD group before and after 2 weeks of treatment, and (3) the percentage of patients who transitioned to surgery because of failure to the conservative treatment. A total of 106 consecutive patients were enrolled in this study for analysis; 54 patients received atorvastatin-based treatment (control group), and 52 were treated with both atorvastatin-based treatment and cMLD (cMLD group). At baseline, the mean hematoma volume was 76.53 ± 42.97 ml in the control group and 88.57 ± 49.01 ml in the cMLD group (p = 0.181). In the 4th week, the absolute number of hematoma reductions (20.79 ± 34.73 ml vs. 37.28 ± 28.24 ml, p = 0.009) and percentage of hematoma reductions (22.58% ± 60.01% vs. 46.43% ± 30.12%, p = 0.012) in the cMLD group were greater than those in the control group. After 2 weeks of treatment, the absolute number of hematoma reductions showed no difference in the two groups, while the percentage of hematoma reduction was higher in the cMLD group (18.18% ± 24.61% vs. 2.08% ± 25.72%, p = 0.001). One patient in cMLD and 8 patients in the control group were transitioned to receive surgical treatment. The dCLN volumes in 23 experimental patients increased significantly after 2 weeks of treatment in the cMLD group (p = 0.032). There were no severe side effects that needed to be reported. Combined with atorvastatin-based therapy, cMLD can promote hematoma absorption and decrease the surgery rate, which provides a new therapeutic strategy for CSDH.

Efficacy of atorvastatin administration after surgery in patients with chronic subdural hematoma

To explore the clinical efficacy of atorvastatin administration after surgery in patients with chronic subdural hematoma. We conducted a retrospective study to analyze the clinical data of patients with chronic subdural hematoma. Patients receiving atorvastatin treatment after surgery were divided into the study group while others were divided into the control group. As the primary outcome, we compared the hematoma recurrence rate. The secondary outcomes were the remaining volume of hematoma and the activities of daily living (Barthel index) score at 3 months after discharge. A total of 53 patients were included in the study: 30 patients in the study group (n = 30) and 23 patients in the control group (n = 23). The baseline clinical data were similar in the 2 groups (P > .05). Four patients had recurrence of hematoma in the study group, while 5 patients had recurrence of hematoma in the control group [4/30 (13.3%) versus 5/23 (21.7%), P = .661] at 3 months after discharge. The mean remaining volume of hematoma was 12.10 ± 8.80 mL in the study group and 17.30 ± 9.50 mL in the control group at 3 months after discharge, respectively. The remaining volume of hematoma in the study group was less than that in the control group (P = .045).The activities of daily living score in the study group were higher than those in the control group (97.83 ± 4.48 vs 94.78 ± 5.73, P = .034) at 3 months after discharge. Atorvastatin administration after surgery barely reduce the recurrence rate of chronic subdural hematoma, however, reduced the remaining volume of hematoma and improved neurological function.

Medical Management of Chronic Subdural Hematoma

Chronic subdural hematoma (CSDH) is a commonly encountered disease in the field of neurosurgery, typically resulting from head trauma. Several medical treatments have been introduced to manage patients with CSDH though surgical drainage is the main strategy to manage symptomatic patients. This review is aimed to meticulously examine contemporary pharmacological approaches, based on a thorough understanding of CSDH pathophysiology. Finally, the review offers a glance into future perspectives to enhance the management of CSDH.

Surgical treatment of chronic subdural hematoma by twist drill craniotomy: A 9-year, single-center experience of 219 cases

OBJECTIVE

This study aims to assess the safety and efficiency of twist drill craniotomy (TDC) for surgical treatment of chronic subdural hematoma (CSDH) based on a single-center experience of 219 cases performed over nine years.

METHODS

We performed a retrospective analysis of CSDH patients who underwent TDC treatment in our hospital between January 2013 and December 2021. Clinical and radiological characteristics, as well as surgical outcomes of the included patients, were reviewed and analyzed. Factors that may affect hematoma recurrence and outcomes were also investigated.

RESULTS

A total of 219 patients (186 males and 33 females) were included. Eighteen (8.2%) patients experienced postoperative complications. The in-hospital mortality and recurrence rates in our series were 0.5% (1/219) and 4.1% (9/217), respectively. 91.7% (199/217) of patients achieved favorable outcomes six months after the operation. Duration of drainage catheter (odds ratio [OR] 0.135, 95% confidence interval [CI] 0.017-1.099; P = 0.030) was the only factor significantly related to the recurrence of CSDH. Moreover, brain infarction (OR 5.175, 95% CI 1.417-18.896; P = 0.013), Alzheimer's disease (OR 20.515, 95% CI 1.950-215.840; P = 0.012), and preoperative dysfunction of coagulation (OR 6.509, 95% CI 1.501-28.217; P = 0.012) were markedly associated with unfavorable functional outcomes.

CONCLUSION

TDC with irrigation and closed-system drainage is a minimally invasive, simple, safe, and effective surgical technique that can serve as the first-choice for the treatment of CSDH with a low recurrence rate.

Mini-Perforated Craniotomy with Subperiosteal Drain for Evacuation of Chronic Subdural Hematoma: A New Technique and Clinical Study

Purpose Chronic subdural hematoma (cSDH) is a frequent disease of the elderly with favorable outcomes. The main choice of treatment is surgery. Along with many surgical techniques described for evacuation of cSDH, we are presenting the preliminary outcomes of a novel surgical method, mini-perforated craniotomy with a subperiosteal drain.

Materials and Methods Patients in whom cSDH with thickness of >10 mm was observed in computed tomography (CT) scans with parenchymal compression and/or midline shift were included in this study. Age, sex, complaint, neurological status, and medical history were recorded along with CT findings. Mini-perforated craniotomy was performed on all patients. A subperiosteal drain was used. The postoperative follow-up period was 3 months.

Results Ten cSDH patients who were admitted to Prof. Dr. Cemil Tascioglu City Hospital between December 2020 and May 2021 were included in this study. The mean age was 64.3 ± 6.272, and the most common admission complaint was a headache. Postoperatively, one patient showed acute rebleeding after the operation due to dual anticoagulant therapy. Besides, in 3 months follow-up, rebleeding, subdural or epidural effusion, wound infection, or cosmetic problems were not observed.

Conclusion Mini-perforated craniotomy with a subperiosteal drain may be an alternative method for evacuation of cSDH with low complication rates especially when the hematoma is suspected to be septated.

The inflammatory cellular feature in the peripheral blood of chronic subdural hematoma patients

Background

Chronic subdural hematoma (CSDH) is a common neurosurgical disease with an increasing incidence. The absorption route of CSDH is not clear. Whether inflammatory factors enter the peripheral blood and cause systemic reactions is unknown.

Methods

We screened 105 CSDH patients and 105 control individuals. Their clinical characteristics and blood routine results were collected and compared. The blood routine changes of CSDH patients before and after treatment were compared. Age‐stratified analysis was performed due to age may affect the inflammatory markers.

Results

The white blood cell count, absolute neutrophil count, neutrophil percentage, neutrophil‐lymphocyte count ratio (NLR), and platelet to lymphocyte count ratio (PLR) of CSDH patients before treatment were within the normal range, while were significantly higher than the control individuals (p < 0.001). The absolute lymphocyte count and lymphocyte percentage of control individuals were higher than those of patients (p < 0.001). The inflammatory cells in patients of different age groups were similar. After the patient was cured, the white blood cell count, the absolute value and percentage of neutrophils decreased (p < 0.05), while the number of monocytes increased.

Conclusions

CSDH caused slight systemic inflammatory responses in the peripheral blood, implying that there is a non‐hematologic route for the absorption of hematoma.

Immunoexpression of MMP-8 and MMP-9 in chronic subdural hematoma

To determine the possible role of matrix metallopeptidase (MMP)-8 and MMP-9 in the development of chronic subdural hematoma (CSDH), we investigated their expression in CSDH. In our previous study, we analyzed hematoma fluid and peripheral blood of 83 patients with CSDH, including 17 postoperative patients. Based on these results, we included 50 people in the normal group and analyzed 20 markers in the peripheral blood of each person. In order to identify representative markers, it was assessed by using overall differential gene expression. The concentration of MMP-8 was significantly higher in the normal group than that in the preoperative and postoperative groups. The concentration of MMP-9 was significantly lower in the normal group than in both preoperative and postoperative groups. Immunohistochemistry confirmed the expression of MMP-8 and MMP-9 in CSDH membranes. In conclusion, our results provide evidence of the expression of MMP-8 and MMP-9 in CSDH. In addition, the expression of MMP-8 and MMP-9 suggests angiogenesis in CSDH formation.

Evaluation of Traumatic Subdural Hematoma Volume by Using Image Segmentation Assessment Based on Deep Learning

Rapid and accurate evaluations of hematoma volume can guide the treatment of traumatic subdural hematoma. We aim to explore the consistency between the measurement results of traumatic subdural hematoma (TSDH) using a deep learn-based image segmentation algorithm. A retrospective study was conducted on 90 CT images of patients diagnosed with TSDH in our hospital from January 2019 to January 2022. All image data were measured by manual segmentation, convolutional neural networks (CNN) algorithm segmentation, and ABC/2 volume formula. With manual segmentation as the “golden standard,” a consistency test was carried out with CNN algorithm segmentation and ABC/2 volume formula, respectively. The percentage error of CNN algorithm segmentation is less than ABC/2 volume formula. There is no significant difference between CNN algorithm segmentation and manual segmentation (P > 0.05). The area under curve of the ABC/2 volume formula, manual segmentation, and CNN algorithm segmentation is 0.811 (95% CI: 0.717~0.905), 0.840 (95% CI: 0.753~0.928), and 0.832 (95% CI: 0.742~0.922), respectively. From our results, the algorithm based on CNN has a good efficiency in segmentation and accurate calculation of TSDH hematoma volume.

Surgical Treatment of Bilateral Chronic Subdural Hematoma

Background

Chronic subdural hematoma (CSDH) is one of the common clinical intracranial hemorrhagic disorders, accounting for 16%-20% of bilateral CSDH. At present, the surgical treatment of bilateral CSDH mainly includes drilling drainage and neuroendoscopic assistance. The main objective of this paper was to compare the effects of two surgical methods on CSDH.

Methods

153 patients who were diagnosed with CSDH were included in this study. 79 patients were treated with bilateral drilling drainage, and the other 74 patients were treated with neuroendoscope-assisted drainage. The clinical data of the two groups were compared, and the surgical indexes, neurological function, cure rate, and recurrence rate of the two groups were compared. The operation indexes of patients include operation time, postoperative hematoma volume, hospital stay, extubation time, misplacement of drainage tube, recurrence, and hematoma clearance rate.

Results

All patients underwent CT  examination one day after operation. The CT  imaging detection of the two groups was generally good. The cranial CT was reexamined before discharge. The bilateral hematoma disappeared in 114 patients, the unilateral hematoma disappeared in 29 patients, a small amount of compensatory crescent very low-density shadow subdural effusion was observed on the other side, and a small amount of compensatory crescent very low-density shadow subdural effusion was observed on both sides in 10 patients. There was no space occupying effect and intracranial gas disappeared. Compared with neuroendoscopic assisted drainage, the operation time of drilling drainage patients was significantly shorter. The extubation time, drainage tube dislocation, recurrence rate, postoperative hematoma volume, and hematoma clearance rate of patients receiving neuroendoscopic assisted drainage were significantly better than those receiving drilling drainage. The Markwalder score and hospital stay between the two groups were not significant.

Conclusions

Drilling drainage and neuroendoscopic assisted surgery have good therapeutic effects on bilateral CSDH. The operation time of drilling drainage is shorter. Neuroendoscopic assisted surgery has more advantages in extubation time, misplacement of drainage tube, recurrence, postoperative hematoma volume, and hematoma clearance rate.

Serum Levels of MMP-8 and MMP-9 as Markers in Chronic Subdural Hematoma

Chronic subdural hematoma (CSDH) is a common neurological disease that involves the collection of blood products in the subdural space. The progression of CSDH is an angiogenic and inflammatory process, but the multifactorial mechanisms underlying CSDH are still not fully understood. We aimed to identify one or more factors that may play an important role in the development of CSDH. We enrolled 83 patients with CSDH, including 17 postoperative patients, and analyzed 20 markers in the hematoma fluid and peripheral blood of each patient. Overall differential gene expression was examined to identify the representative markers. The concentration of MMP-8 was significantly lower in the postoperative group than in the preoperative group. The concentration of MMP-9 was significantly higher in the postoperative group than in the preoperative group. These findings indicate that MMP-8 and MMP-9 may play important roles in the pathophysiology of CSDH. Understanding the pathways associated with CSDH may provide insights for improving disease outcomes.

The Efficacy of Adjuvant Corticosteroids in Surgical Management of Chronic Subdural Hematoma: A Systematic Review and Meta-Analysis

Objective: This systematic review aimed to assess the efficacy of adjuvant corticosteroids in managing patients with chronic subdural hematoma (CSDH) undergoing surgical intervention.

Methods: We searched for eligible studies electronically on the databases of PubMed, Embase, and Google Scholar. The last date of the search was 15th Jun 2021. Outcomes were pooled to calculate risk ratios (RR) with 95% confidence intervals (CI).

Results: Eleven studies were included. Four of them were randomized controlled trials (RCTs). Six studies reported data on good neurological outcomes but with variable definitions. Combining all studies, we noted no statistically significant difference in good neurological outcome with the use of adjuvant corticosteroids (RR: 0.91 95% CI: 0.74, 1.12 I² = 92% p = 0.39). Similar results were obtained on subgroup analysis based on definition and study type. However, the use of adjuvant corticosteroids was associated with a significantly reduced risk of recurrence (RR: 0.51 95% CI: 0.40, 0.64 I² = 0% p < 0.0001). The meta-analysis also demonstrated no statistically significant difference in mortality rates with the use of adjuvant corticosteroids (RR: 1.01 95% CI: 0.47, 2.21 I² = 76% p = 0.97). The results did not differ between RCTs and non-RCTs. Limited studies reported data on complications, and pooled analysis indicated no significant increase in infectious, gastrointestinal, and neurological complications with the use of adjuvant corticosteroids.

Conclusion: The use of corticosteroids with surgery for CSDH might be associated with a reduction in recurrence rate. However, corticosteroids do not improve functional outcomes or mortality rates. Future studies should assess the impact of different corticosteroid regimens on patient outcomes, and should use standardized reporting of neurological outcomes with uniform follow-up duration.

Atorvastatin combined with dexamethasone in chronic subdural haematoma (ATOCH II): study protocol for a randomized controlled trial

BACKGROUND

Chronic subdural haematoma (CSDH) is a common condition in the elderly that often requires neurosurgical management. For small CSDH, evidence has emerged that statins may reduce haematoma volume and improve outcomes, presumably by reducing local inflammation and promoting vascular repair. We wish to extend this evidence in a study that aims to determine the efficacy and safety of atorvastatin combined with low-dose dexamethasone in patients with CSDH.

METHODS

The second ATorvastatin On Chronic subdural Hematoma (ATOCH-II) study is a multi-centre, randomized, placebo-controlled, double-blind trial which aims to enrol 240 adult patients with a conservative therapeutic indication for CSDH, randomly allocated to standard treatment with atorvastatin 20 mg combined with low-dose dexamethasone (or matching placebos) daily for 28 days, and with 152 days of follow-up. The primary outcome is a composite good outcome defined by any reduction from baseline in haematoma volume and survival free of surgery at 28 days. Secondary outcomes include functional outcome on the modified Rankin scale (mRS) and modified Barthel Index at 28 days, surgical transition and reduction in haematoma volumes at 14, 28 and 90 days.

DISCUSSION

This multi-centre clinical trial aims to provide high-quality evidence on the efficacy and safety of the combined treatment of atorvastatin and low-dose dexamethasone to reduce inflammation and enhance angiogenesis in CSDH.

TRIAL REGISTRATION

ChiCTR, ChiCTR1900021659 . Registered on 3 March 2019, http://www.chictr.org.cn/showproj.aspx?proj=36157 .

Atorvastatin combined with dexamethasone promote hematoma absorption in an optimized rat model of chronic subdural hematoma

Previous studies found that atorvastatin and dexamethasone were effective in promoting the absorption of chronic subdural hematoma. In this study, we aimed to investigate the effect of pharmacotherapy in an optimized rat model of chronic subdural hematoma. Rat model of chronic subdural hematoma via a bEnd.3 cell and Matrigel mix was established and dynamic changes in different drug treatment groups were tested. The hematoma gradually increased, peaked on the fifth day (263.8±52.85 μl), and was completely absorbed in two weeks. Notably, Kruppelle-like factor 2 expression was significantly decreased with increasing hematoma volume, and then increased in the repair period. The expression of IL-10 was increased and peaked on 7 days, and then decreased at 14 days. The dynamic trends of IL-6, IL-8, MMP-9, and VEGF were also increased first and then decreased. Both monotherapy and the combined treatment by atorvastatin and dexamethasone could counteract the inflammatory activities, decrease hematoma permeability, and improve hematoma absorption, however, most prominent in combined group. The combined treatment could more effectively increase Kruppelle-like factor 2 and ZO-1 expression, attenuate the expression of NF-κb. Most importantly, the combined treatment enhanced the neural functional prognosis and reduced the mortality of chronic subdural hematoma rats. According to our results, the combined treatment could more effectively attenuate inflammatory. And it could also enhance angiogenic activities which could promote the stability of local function and structure of the hematoma cavity, reduce the hematoma volume and improve the outcomes of rats with chronic subdural hematoma than single treatments in the optimized chronic subdural hematoma model.

Steroid in Chronic Subdural Hematoma: An Updated Systematic Review and Meta-Analysis Post DEX-CSDH Trial

BACKGROUND

Chronic subdural hematoma (CSDH) is a neurologic condition characterized as a hematoma in the subdural space with a period >3 weeks that primarily affects the elderly. Glucocorticoid, especially dexamethasone, either alone or combined with surgery, has been used to manage CSDH. We aimed to perform an updated systematic review and meta-analysis of the literature regarding the role of steroids in CSDH.

METHODS

We searched the electronic databases PubMed, PubMed Central, Scopus, and Embase for relevant articles until December 2020. Study characteristics, quality, and end points were extracted, and analysis was performed by RevMan 5.4.

RESULTS

The odds for subdural hematoma recurrence were decreased by 61% in the steroid group (odds ratio [OR], 0.39; confidence interval [CI], 0.19-0.79) compared with the control group. There was no significant difference in mortality during the study period (OR, 0.66; CI, 0.20-2.18), modified Rankin Scale score 0-3 (OR, 0.87; CI, 0.31-2.40), and modified Rankin Scale score 4-6 (OR, 1.15; CI, 0.42-3.18) between the 2 groups. However, pooling data from 3 studies showed 2.7 times higher odds of occurring adverse effects in steroid groups using the fixed-effect model (OR, 2.70; CI, 1.71-4.28). The treatment success was similar between the steroid and control groups (OR, 2.39; CI, 0.94-6.04).

CONCLUSIONS

Treatment with steroids was associated with a lesser recurrence of CSDH. However, there was no benefit of steroid treatment in CSDH compared with nonsteroid treatment in terms of mortality and treatment success and some but significantly increased risk of adverse events.

Pharmacological Treatment in the Management of Chronic Subdural Hematoma

Background: Several pharmacological treatments have been used to treat patients with chronic subdural hematoma (CSDH), although little is known about the comparative effectiveness of different classes of medication. We performed a Bayesian network meta-analysis to compare and rank the efficacy and safety of five drug regimens to determine the best treatment for this group of patients. Methods: We systematically searched PubMed, Medline, clinicaltrials.gov, the Cochrane database, and Embase to identify relevant randomized clinical trials (RCTs) comparing drug treatments in adult patients with CSDH. A network meta-analysis was conducted using a Bayesian framework. Random- and fixed-effects models were used to pool the network results, and the preferred model was selected by comparing the deviance information criteria (DIC). Efficacy outcomes included recurrence requiring surgery, changes in hematoma volume, and a good recovery. The safety outcomes were treatment-related adverse events and all-cause mortality. Results: In this Bayesian network meta-analysis, available data were obtained from 12 eligible trials, including 2,098 patients and 5 techniques. Compared to placebo, atorvastatin (RR: 0.45, 95% CrI: 0.24-0.81) and dexamethasone (RR: 0.38, 95% CrI: 0.22-0.63) were similarly effective in reducing recurrence requiring surgery by 55% and 62%, respectively. Dexamethasone (RR: 0.46, 95% CrI: 0.23-0.91) was more effective in reducing recurrence requiring surgery than goreisan. Additionally, atorvastatin reduced the hematoma volume to a greater extent than placebo (MD: -7.44, 95% CrI: -9.49 to -5.43) or goreisan (MD: -14.09, 95% CrI: -23.35 to -4.82). Moreover, tranexamic acid (MD: -12.07, 95% CrI: -21.68 to -2.29) reduced the hematoma volume to a greater extent than goreisan. No significant differences were detected between drugs and placebo with regard to a good recovery. In terms of safety, dexamethasone (RR: 1.96, 95% CrI: 1.20-3.28) increased the risk of mortality compared to placebo. Conclusion: These findings suggest that dexamethasone is the best treatment to reduce recurrence and atorvastatin is the best treatment to reduce hematoma volume in patients with CSDH. However, clinicians should pay close attention to the elevated risk of all-cause mortality and potential adverse events caused by dexamethasone. Future well-designed RCTs with more participants are needed to verify these findings. Clinical Trial Registration: http://osf.io/u9hqp.

The Mini-Craniotomy for cSDH Revisited: New Perspectives

Background: Chronic subdural hematomas (cSDH) are increasingly prevalent worldwide with the increased aging population and anticoagulant use. Different surgical, medical, and endovascular treatments have had varying success rates. Primary neurosurgical interventions include burr hole drainage of the cSDH and mini-craniotomies/craniotomies with or without fenestration of the inner membrane. A key assessment of the success or failure of cSDH treatments has been symptomatic recurrence rates which have historically ranged from 5 to 30%. Pre-operative prediction of the inner subdural membrane by CT scan was used to guide our decision to perform mini-craniotomies. Release of the inner membrane facilitates the expansion of the brain and likely improves glymphatic flow.

Methods: Consecutive mini-craniotomies (N = 34) for cSDH evacuation performed by a single neurosurgeon at a quaternary academic medical center/Level I trauma center from July 2018-September 2020 were retrospectively reviewed. Patient characteristics [age, gender, presenting GCS, GOS, initial CTs noting the inner subdural membrane, midline shift (MLS), cSDH width, inner membrane fenestration, cSDH recurrence, post-operative seizures, infections, length of stay] were extracted from the EMR.

Results: Twenty nine patients had mini-craniotomies as primary treatment of the cSDH. Mean age = 68.9 ± 19.7 years (range 22–102), mean pre-operative GCS = 14.5 ± 1.1, mean MLS = 6.75 ± 4.2 mm, and mean maximum thickness of cSDH = 17.7 ± 6.0 mm. Twenty four were unilateral, five bilateral, 34 total craniotomies were performed. Thirty three had inner membrane signs on pre-operative head CTs and an inner subdural membrane was fenestrated in all cases except for the one craniotomy that didn't show these characteristic CT findings. Mean operating time = 79.5 ± 26.0 min. Radiographic and clinical improvement occurred in all patients. Mean improvement in MLS = 3.85 ± 2.69. There were no symptomatic recurrences, re-operations, surgical site infections, or deaths during the 6 months of follow-up. One patient was treated for post-operative seizures with AEDs for 6 months.

Conclusion: Pre-operative CT scans demonstrating inner subdural membranes may guide one to target the treatment to allow release of this tension band. Mini-craniotomy with careful fenestration of the inner membrane is very effective for this. Brain re-expansion and re-establishment of normal brain interstitial flow may be important in long term outcomes with cSDH and may be related to the recent interests in brain glymphatics and dural lymphatics.

A novel rat model of chronic subdural hematoma: Induction of inflammation and angiogenesis in the subdural space mimicking human-like features of progressively expanding hematoma

Pathophysiological mechanisms of chronic subdural hematoma (CSDH) involve localized inflammation, angiogenesis, and dysregulated coagulation and fibrinolysis. The scarcity of reproducible and clinically relevant animal models of CSDH hinders further understanding the underlying pathophysiology and improving new treatment strategies. Here, we developed a novel rat model of CSDH using extracellular matrices (Matrigel) and brain microvascular endothelial cell line (bEnd.3 cells). One hundred-microliter of Matrigel-bEnd.3 cell (10⁶ cells per milliliter) mixtures were injected into the virtual subdural space of elderly male Sprague-Dawley rats. This approach for the first time led to a spontaneous and expanding subdural hematoma, encapsulated by internal and external neomembranes, formed as early as 3 d, reached its peak at 7 d, and lasted for more than 14 d, mimicking the progressive hemorrhage observed in patients with CSDH. The external neomembrane and hematoma fluid involved numerous inflammatory cells, fibroblasts, and highly fragile neovessels. Furthermore, a localized pathophysiological process was validated as evidenced by the increased expressions of inflammatory and angiogenic mediators in external neomembrane and hematoma fluid rather than in peripheral blood. Notably, the specific expression profiles of these mediators were closely associated with the dynamic changes in hematoma volume and neurological outcome. In summary, the CSDH model described here replicated the characteristics of human CSDH, and might serve as an ideal translational platform for preclinical studies. Meanwhile, the crucial roles of angiogenesis and inflammation in CSDH formation were reaffirmed.