1
|
Sağıroğlu S, Şirin C, Turgut AÇ, Tomruk C, Tuzcu A, Ertekin E, Uyanıkgil Y, Turgut M. Investigation of the Efficacy of Bevacizumab Treatment in An Experimental Rat Model of Chronic Subdural Hematoma. World Neurosurg 2024; 189:e272-e286. [PMID: 38871290 DOI: 10.1016/j.wneu.2024.06.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Accepted: 06/07/2024] [Indexed: 06/15/2024]
Abstract
INTRODUCTION Chronic subdural hematoma (cSDH), a condition that develops over time, is characterized by inflammation, angiogenesis, and membrane development. As the population's average age increases, the incidence of cSDH is expected to grow. While surgery is the primary treatment technique, medicinal therapy options are being explored for high-risk patients. Currently, the most effective therapy combination is dexamethasone (Dex) and atorvastatin (Ato); however, it is associated with an increased risk of mortality. This study explored the effects of bevacizumab (Bev), a vascular endothelial growth factor antagonist, on cSDH. MATERIALS AND METHODS Ninety-five rats were divided into four groups (n = 18): sham, control hematoma, Dex-Ato, and Bev. Two separate autologous blood injections into the subdural space were used as the model. Weight was monitored for all rats to assess changes in their overall health. The control group was given i.p. saline, the Dex-Ato treatment was given by gavage, and the Bev treatment was given i.p. On seventh, 14th and 21st days six rats from each group were sacrificed and analyzed, while 23 rats were excluded from the experiment. RESULTS The maximum immunological response to cSDH was observed on day 14. Hematoma volume decreased over time in all groups. Dex-Ato and Bev were both found effective, while Dex-Ato caused weight loss. CONCLUSION Bev had similar effects to the Dex-Ato group and was well tolerated by rats. Given that cSDH is a disease of the elderly and vulnerable populations, Bev may be a viable alternative that can shed light on the disease's etiology for future research.
Collapse
Affiliation(s)
- Sinan Sağıroğlu
- Department of Neurosurgery, Aydın Adnan Menderes University Faculty of Medicine, Aydın, Turkey
| | - Cansın Şirin
- Department of Histology and Embryology, Ege University Faculty of Medicine, İzmir, Turkey
| | - Ali Çağlar Turgut
- Department of Radiology, Ege University Faculty of Medicine, İzmir, Turkey; Department of Histology and Embryology, Aydın Adnan Menderes University Health Sciences Institute, Aydın, Turkey
| | - Canberk Tomruk
- Department of Histology and Embryology, Samsun Education and Research Hospital, Samsun, Turkey
| | - Ayça Tuzcu
- Department of Biochemistry, Aydın Adnan Menderes University Faculty of Medicine, Aydın, Turkey
| | - Ersen Ertekin
- Department of Radiology, Hitit University Faculty of Medicine, Çorum, Turkey
| | - Yiğit Uyanıkgil
- Department of Histology and Embryology, Ege University Faculty of Medicine, İzmir, Turkey; Department of Stem Cell, Ege University, Health Science Institute, İzmir, Turkey; Cord Blood, Cell and Tissue Research and Application Centre, Ege University, İzmir, Turkey
| | - Mehmet Turgut
- Department of Neurosurgery, Aydın Adnan Menderes University Faculty of Medicine, Aydın, Turkey; Department of Histology and Embryology, Aydın Adnan Menderes University Health Sciences Institute, Aydın, Turkey.
| |
Collapse
|
2
|
Schmolling ÁH, Pérez-García C, Trejo C, López-Frías A, Jaroenngarmsamer T, Rosati S, Arrazola J, Moreu M. Middle Meningeal Artery Embolization for Management of Chronic Subdural Hematoma. Radiographics 2024; 44:e230158. [PMID: 38451847 DOI: 10.1148/rg.230158] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
Chronic subdural hematoma (CSDH) is a prevalent medical condition with potentially severe consequences if left untreated. While surgical removal has traditionally been the standard approach for treatment, middle meningeal artery (MMA) embolization has emerged as a promising minimally invasive alternative to reduce recurrences. This comprehensive review provides the general radiology community with an overview of MMA embolization as a therapeutic option for managing CSDH. The authors base their insights on existing evidence and their institutional experience. This overview encompasses the pathophysiology of CSDH as well as the potential advantages and limitations, safety profile, and potential complications of MMA embolization as compared with surgical treatment. The imaging findings seen before and after MMA, as well as insights into the procedural techniques used at the authors' institution, are described. On the basis of reports in the current literature, MMA embolization appears to be a safe and effective therapeutic option for managing CSDH, especially in patients who are unsuitable for surgery or at risk for recurrence. Nonetheless, further research is needed to validate these findings. Results from ongoing clinical trials hold promise for future validation and the establishment of scientific evidence. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material. See the invited commentary by Chatterjee in this issue.
Collapse
Affiliation(s)
- Ángela H Schmolling
- From the Departments of Interventional Neuroradiology (A.H.S., C.P.G., C.T., A.L.F., S.R., M.M.) and Radiology (J.A.), Hospital Clínico San Carlos, Calle del Profesor Martín Lagos s/n, 28040 Madrid, Spain; and Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (T.J.)
| | - Carlos Pérez-García
- From the Departments of Interventional Neuroradiology (A.H.S., C.P.G., C.T., A.L.F., S.R., M.M.) and Radiology (J.A.), Hospital Clínico San Carlos, Calle del Profesor Martín Lagos s/n, 28040 Madrid, Spain; and Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (T.J.)
| | - Carmen Trejo
- From the Departments of Interventional Neuroradiology (A.H.S., C.P.G., C.T., A.L.F., S.R., M.M.) and Radiology (J.A.), Hospital Clínico San Carlos, Calle del Profesor Martín Lagos s/n, 28040 Madrid, Spain; and Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (T.J.)
| | - Alfonso López-Frías
- From the Departments of Interventional Neuroradiology (A.H.S., C.P.G., C.T., A.L.F., S.R., M.M.) and Radiology (J.A.), Hospital Clínico San Carlos, Calle del Profesor Martín Lagos s/n, 28040 Madrid, Spain; and Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (T.J.)
| | - Tanaporn Jaroenngarmsamer
- From the Departments of Interventional Neuroradiology (A.H.S., C.P.G., C.T., A.L.F., S.R., M.M.) and Radiology (J.A.), Hospital Clínico San Carlos, Calle del Profesor Martín Lagos s/n, 28040 Madrid, Spain; and Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (T.J.)
| | - Santiago Rosati
- From the Departments of Interventional Neuroradiology (A.H.S., C.P.G., C.T., A.L.F., S.R., M.M.) and Radiology (J.A.), Hospital Clínico San Carlos, Calle del Profesor Martín Lagos s/n, 28040 Madrid, Spain; and Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (T.J.)
| | - Juan Arrazola
- From the Departments of Interventional Neuroradiology (A.H.S., C.P.G., C.T., A.L.F., S.R., M.M.) and Radiology (J.A.), Hospital Clínico San Carlos, Calle del Profesor Martín Lagos s/n, 28040 Madrid, Spain; and Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (T.J.)
| | - Manuel Moreu
- From the Departments of Interventional Neuroradiology (A.H.S., C.P.G., C.T., A.L.F., S.R., M.M.) and Radiology (J.A.), Hospital Clínico San Carlos, Calle del Profesor Martín Lagos s/n, 28040 Madrid, Spain; and Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (T.J.)
| |
Collapse
|
3
|
Zawy Alsofy S, Lewitz M, Meyer K, Fortmann T, Wilbers E, Nakamura M, Ewelt C. Retrospective Analysis of Risk Factors for Recurrence of Chronic Subdural Haematoma after Surgery. J Clin Med 2024; 13:805. [PMID: 38337502 PMCID: PMC10856185 DOI: 10.3390/jcm13030805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 01/25/2024] [Accepted: 01/30/2024] [Indexed: 02/12/2024] Open
Abstract
(1) Background: In this study, epidemiological, clinical, therapeutical, and haemostaseological variables were investigated regarding their correlation with the recurrence of chronic subdural haematomas to assess the risk of recurrence more reliably in everyday clinical practice. (2) Methods: In our retrospective study, the electronic records of 90 patients who underwent surgery for a chronic subdural haematoma at our institute between 1 January 2017 and 31 May 2021 were analysed regarding previously defined variables. (3) Results: In the patient collective, 33.33% of the 90 patients experienced a recurrence requiring treatment. The occurrence of a recurrence was not statistically significantly related to age, gender, known alcohol abuse, a specific location, extension over one or both hemispheres, the surgical method, or anticoagulant medication. However, the recurrence was statistically significantly related to haematoma width (p = 0.000007), septation (p = 0.005), and the existence of a coagulation disorder not treated with medication (p = 0.04). (4) Conclusions: In our study, the width of the haematoma, septation, and coagulation disorders not treated with medication were documented as risk factors for the occurrence of a chronic subdural haematoma. Identifying of these risk factors could help in adapting individual therapeutic concepts for chronic subdural haematomas.
Collapse
Affiliation(s)
- Samer Zawy Alsofy
- Department of Medicine, Faculty of Health, Witten/Herdecke University, 58448 Witten, Germany; (M.L.); (T.F.); (E.W.)
- Department of Neurosurgery, St. Barbara-Hospital, Academic Hospital of Westfaelische Wilhelms-University Muenster, 59073 Hamm, Germany; (K.M.); (C.E.)
| | - Marc Lewitz
- Department of Medicine, Faculty of Health, Witten/Herdecke University, 58448 Witten, Germany; (M.L.); (T.F.); (E.W.)
- Department of Neurosurgery, St. Barbara-Hospital, Academic Hospital of Westfaelische Wilhelms-University Muenster, 59073 Hamm, Germany; (K.M.); (C.E.)
| | - Kyra Meyer
- Department of Neurosurgery, St. Barbara-Hospital, Academic Hospital of Westfaelische Wilhelms-University Muenster, 59073 Hamm, Germany; (K.M.); (C.E.)
| | - Thomas Fortmann
- Department of Medicine, Faculty of Health, Witten/Herdecke University, 58448 Witten, Germany; (M.L.); (T.F.); (E.W.)
- Department of Neurosurgery, St. Barbara-Hospital, Academic Hospital of Westfaelische Wilhelms-University Muenster, 59073 Hamm, Germany; (K.M.); (C.E.)
| | - Eike Wilbers
- Department of Medicine, Faculty of Health, Witten/Herdecke University, 58448 Witten, Germany; (M.L.); (T.F.); (E.W.)
- Department of Neurosurgery, St. Barbara-Hospital, Academic Hospital of Westfaelische Wilhelms-University Muenster, 59073 Hamm, Germany; (K.M.); (C.E.)
| | - Makoto Nakamura
- Department of Neurosurgery, Academic Hospital Koeln-Merheim, Witten/Herdecke University, 51109 Koeln, Germany;
| | - Christian Ewelt
- Department of Neurosurgery, St. Barbara-Hospital, Academic Hospital of Westfaelische Wilhelms-University Muenster, 59073 Hamm, Germany; (K.M.); (C.E.)
| |
Collapse
|
4
|
De Maria L, Chaurasia B, Agosti E, Garg K, Burkhardt JK, Goehre F, Borghei-Razavi H, Servadei F, Fontanella MM. Non-surgical management of chronic subdural hematoma: insights and future perspectives from an international survey including neurosurgeons from 90 countries worldwide. Int J Neurosci 2023:1-10. [PMID: 37982390 DOI: 10.1080/00207454.2023.2286202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 11/15/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Chronic subdural hematoma (cSDH) is one of the most common neurosurgical conditions. Although surgical evacuation is still the gold standard for treatment, recent advances have led to the development of other management strategies, such as medical therapies and endovascular middle meningeal artery (MMA) embolization. Through this international survey, we investigated the global trends in cSDH management, focusing on medical and endovascular treatments. DESIGN AND PARTICIPANTS A 14-question, web-based, anonymous survey was distributed to neurosurgeons worldwide. RESULTS Most responders do not perform MMA embolization (69.5%) unless for specific indications (29.6%). These indications include residual cSDH after surgical evacuation (58.9%) or cSDH in patients on antiplatelet medications to avoid surgical evacuation (44.8%). Survey participants from teaching versus non-teaching hospitals (p = 0.002), public versus private hospitals (p = 0.022), and Europe versus other continents (p < 0.001) are the most users of MMA embolization. A large number of participants (51%) declare they use a conservative/medical approach, mainly to avoid surgery in patients with small cSDH (74.8%). CONCLUSIONS This survey highlights the current trends of cSDH management, focusing on conservative and MMA embolization treatment strategies. Most responders prefer a conservative approach for patients with small cSDHs not requiring surgical evacuation. However, in higher-risk scenarios such as residual hematomas after surgery or patients on antiplatelet medications, MMA embolization is regarded as a reasonable option by participants. Future studies should clarify the indications of MMA embolization, including appropriate patient selection and efficacy as a stand-alone procedure.
Collapse
Affiliation(s)
| | | | | | - Kanwaljeet Garg
- Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Jan-Karl Burkhardt
- Neurosurgery, Hospital of the University of Pennysylvania, Philadelphia, PA, USA
| | - Felix Goehre
- Neurosurgery, Bergmannstrost Hospital Halle, Halle, Germany
| | | | - Franco Servadei
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- IRCCS Humanitas Research Hospital, Milan, Italy
| | | |
Collapse
|
5
|
Eun J, Ahn S, Lee MH, Choi JG, Kim YI, Cho CB, Park JS. Potential impact of high-density lipoprotein cholesterol in the postoperative outcomes of chronic subdural hematoma patients: multi-institutional study in Korea. Lipids Health Dis 2023; 22:197. [PMID: 37978499 PMCID: PMC10655259 DOI: 10.1186/s12944-023-01970-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 11/13/2023] [Indexed: 11/19/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Jin Eun
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Stephen Ahn
- Department of Neurosurgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Min Ho Lee
- Department of Neurosurgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jin-Gyu Choi
- Department of Neurosurgery, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Young Il Kim
- Department of Neurosurgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Chul Bum Cho
- Department of Neurosurgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jae-Sung Park
- Department of Neurosurgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| |
Collapse
|
6
|
Kipele M, Buchfelder M, Taudte RV, Stadlbauer A, Kinfe T, Bozhkov Y. Immunometabolic Profiling of Chronic Subdural Hematoma through Untargeted Mass Spectrometry Analysis: Preliminary Findings of a Novel Approach. Diagnostics (Basel) 2023; 13:3345. [PMID: 37958242 PMCID: PMC10650661 DOI: 10.3390/diagnostics13213345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 10/07/2023] [Accepted: 10/23/2023] [Indexed: 11/15/2023] Open
Abstract
Objective: Metabolomics has growing importance in the research of inflammatory processes. Chronic subdural hematoma (cSDH) is considered to be, at least in part, of inflammatory nature, but no metabolic analyses yet exist. Therefore, a mass spectrometry untargeted metabolic analysis was performed on hematoma samples from patients with cSDH. Methods: A prospective analytical cross-sectional study on the efficacy of subperiosteal drains in cSDH was performed. Newly diagnosed patients had the option of granting permission for the collection of a hematoma sample upon its removal. The samples were analyzed using liquid chromatography-mass spectrometry to obtain different types of metabolites from diverse biochemical classes. The statistical analysis included data cleaning, imputation, and log transformation, followed by PCA, PLS-DA, HCA, and ANOVA. The postoperative course of the disease was followed for 3 months. The metabolite concentrations in the hematoma fluid were compared based on whether a recurrence of the disease was recorded within this time frame. Results: Fifty-nine samples from patients who were operated on because of a cSDH were gathered. Among those, 8 samples were eliminated because of missing metabolites, and only 51 samples were analyzed further. Additionally, 39 samples were from patients who showed no recurrence over the course of a 3-month follow-up, and 12 samples were from a group with later recurrence. We recorded a noticeable drop (35%) in the concentration of acylcarnitines in the "recurrence group", where 10 of the 22 tested metabolites showed a significant reduction (p < 0.05). Furthermore, a noticeable reduction in different Acyl-CoA-dehydrogenases was detected (VLCAD-deficiency p < 0.05, MCAD-deficiency p = 0.07). No further changes were detected between both populations. Conclusions: The current study presents a new approach to the research of cSDH. The measurements presented us with new data, which, to date, are without any reference values. Therefore, it is difficult to interpret the information, and our conclusions should be considered to be only speculative. The results do, however, point in the direction of impaired fatty acid oxidation for cases with later recurrence. As fatty acid oxidation plays an important role in inflammatory energy metabolism, the results suggest that inflammatory processes could be aggravated in cases with recurrence. Because our findings are neither proven through further analyses nor offer an obvious therapy option, their implications would not change everyday practice in the management of cSDH. They do, however, present a further possibility of research that might, in the future, be relevant to the therapy.
Collapse
Affiliation(s)
- Maria Kipele
- Department of Neurosurgery, Erlangen University, 91054 Erlangen, Germany; (M.K.); (M.B.); (A.S.)
| | - Michael Buchfelder
- Department of Neurosurgery, Erlangen University, 91054 Erlangen, Germany; (M.K.); (M.B.); (A.S.)
| | - R. Verena Taudte
- Core Facility for Metabolomics, Department of Medicine, Philipps University Marburg, 35037 Marburg, Germany;
| | - Andreas Stadlbauer
- Department of Neurosurgery, Erlangen University, 91054 Erlangen, Germany; (M.K.); (M.B.); (A.S.)
| | - Thomas Kinfe
- Division of Stereotactic and Functional Neurosurgery, Department of Neurosurgery, Erlangen University, 91054 Erlangen, Germany;
| | - Yavor Bozhkov
- Department of Neurosurgery, Erlangen University, 91054 Erlangen, Germany; (M.K.); (M.B.); (A.S.)
| |
Collapse
|
7
|
Omura Y, Ishiguro T. Middle meningeal artery embolization for chronic subdural hematoma: a systematic review. Front Neurol 2023; 14:1259647. [PMID: 37881312 PMCID: PMC10593964 DOI: 10.3389/fneur.2023.1259647] [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: 07/16/2023] [Accepted: 09/25/2023] [Indexed: 10/27/2023] Open
Abstract
Background Chronic subdural hematoma (cSDH) is one of the most common diseases in neurosurgery. Middle meningeal artery embolization (MMAE) is reportedly an option to prevent recurrence or avoid surgery in patients with cSDH. This study was performed to review the evidence on MMAE for cSDH and evaluate its safety, efficacy, indications, and feasibility. Methods We systematically reviewed the literature according to the PRISMA guidelines using an electronic database. The search yielded 43 articles involving 2,783 patients who underwent MMAE. Results The hematoma resolution, recurrence, and retreatment rates in the MMAE-alone treatment group (n = 815) were 86.7%, 6.3%, and 9.6%, respectively, whereas those in the prophylactic MMAE with combined surgery group (n = 370) were 95.6%, 4.4%, and 3.4%, respectively. The overall MMAE-related complication rate was 2.3%. Conclusion This study shows that MMAE alone is, although not immediate, as effective as evacuation surgery alone in reducing hematoma. The study also shows that combined treatment has a lower recurrence rate than evacuation surgery alone. Because MMAE is a safe procedure, it should be considered for patients with cSDH, especially those with a high risk of recurrence.
Collapse
Affiliation(s)
| | - Taichi Ishiguro
- Department of Neurosurgery, Tokyo Women's Medical University Yachiyo Medical Center, Yachiyo, Chiba, Japan
| |
Collapse
|
8
|
Gao C, Wei Y, Zhang X, Huang J, Nie M, Liu X, Yuan J, Wang D, Tian Y, Jiang W, An S, Sun J, Sha Z, Fan Y, Feng J, Liu M, Dong S, Wu D, Zhang J, Wang J, Jiang R. Craniocervical Manual Lymphatic Drainage Increases the Efficiency of Atorvastatin-Based Treatment of Chronic Subdural Hematoma. Transl Stroke Res 2023; 14:667-677. [PMID: 35907128 DOI: 10.1007/s12975-022-01062-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 06/27/2022] [Indexed: 11/26/2022]
Abstract
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.
Collapse
Affiliation(s)
- Chuang Gao
- Department of Neurosurgery, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, China
- Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in the Central Nervous System, Ministry of Education and Tianjin, Tianjin Neurological Institute, Tianjin, China
| | - Yingsheng Wei
- Department of Neurosurgery, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, China
- Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in the Central Nervous System, Ministry of Education and Tianjin, Tianjin Neurological Institute, Tianjin, China
| | - Xinjie Zhang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, China
- Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in the Central Nervous System, Ministry of Education and Tianjin, Tianjin Neurological Institute, Tianjin, China
| | - Jinhao Huang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, China
- Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in the Central Nervous System, Ministry of Education and Tianjin, Tianjin Neurological Institute, Tianjin, China
| | - Meng Nie
- Department of Neurosurgery, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, China
- Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in the Central Nervous System, Ministry of Education and Tianjin, Tianjin Neurological Institute, Tianjin, China
| | - Xuanhui Liu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, China
- Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in the Central Nervous System, Ministry of Education and Tianjin, Tianjin Neurological Institute, Tianjin, China
| | - Jiangyuan Yuan
- Department of Neurosurgery, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, China
- Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in the Central Nervous System, Ministry of Education and Tianjin, Tianjin Neurological Institute, Tianjin, China
| | - Dong Wang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, China
- Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in the Central Nervous System, Ministry of Education and Tianjin, Tianjin Neurological Institute, Tianjin, China
| | - Ye Tian
- Department of Neurosurgery, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, China
- Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in the Central Nervous System, Ministry of Education and Tianjin, Tianjin Neurological Institute, Tianjin, China
| | - Weiwei Jiang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, China
- Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in the Central Nervous System, Ministry of Education and Tianjin, Tianjin Neurological Institute, Tianjin, China
| | - Shuo An
- Department of Neurosurgery, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, China
- Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in the Central Nervous System, Ministry of Education and Tianjin, Tianjin Neurological Institute, Tianjin, China
| | - Jian Sun
- Department of Neurosurgery, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, China
- Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in the Central Nervous System, Ministry of Education and Tianjin, Tianjin Neurological Institute, Tianjin, China
| | - Zhuang Sha
- Department of Neurosurgery, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, China
- Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in the Central Nervous System, Ministry of Education and Tianjin, Tianjin Neurological Institute, Tianjin, China
| | - Yibing Fan
- Department of Neurosurgery, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, China
- Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in the Central Nervous System, Ministry of Education and Tianjin, Tianjin Neurological Institute, Tianjin, China
| | - Jiancheng Feng
- Department of Neurosurgery, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, China
- Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in the Central Nervous System, Ministry of Education and Tianjin, Tianjin Neurological Institute, Tianjin, China
| | - Mingqi Liu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, China
- Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in the Central Nervous System, Ministry of Education and Tianjin, Tianjin Neurological Institute, Tianjin, China
| | - Shiying Dong
- Department of Neurosurgery, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, China
- Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in the Central Nervous System, Ministry of Education and Tianjin, Tianjin Neurological Institute, Tianjin, China
| | - Di Wu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, China
- Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in the Central Nervous System, Ministry of Education and Tianjin, Tianjin Neurological Institute, Tianjin, China
| | - Jianning Zhang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, China.
- Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in the Central Nervous System, Ministry of Education and Tianjin, Tianjin Neurological Institute, Tianjin, China.
| | - Junping Wang
- Department of Radiology and Tianjin Key Laboratory of Functional Imaging, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, China.
| | - Rongcai Jiang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, China.
- Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in the Central Nervous System, Ministry of Education and Tianjin, Tianjin Neurological Institute, Tianjin, China.
| |
Collapse
|
9
|
Orscelik A, Senol YC, Bilgin C, Kobeissi H, Arul S, Cloft H, Lanzino G, Kallmes DF, Brinjikji W. Middle meningeal artery embolization without surgical evacuation for chronic subdural hematoma: a single-center experience of 209 cases. Front Neurol 2023; 14:1222131. [PMID: 37719752 PMCID: PMC10501738 DOI: 10.3389/fneur.2023.1222131] [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: 05/13/2023] [Accepted: 08/03/2023] [Indexed: 09/19/2023] Open
Abstract
Background Middle meningeal artery (MMA) embolization is a minimally invasive treatment option for new and recurrent chronic subdural hematomas (cSDH). Objective To examine the safety and efficacy profile of MMA embolization without surgical evacuation for cSDH patients. Methods A single-center retrospective study of patients with cSDHs treated by MMA embolization was undertaken. Patient demographics, hematoma characteristics, procedural details, and clinical and radiological outcomes were collected. The primary outcome was the need for retreatment, and the secondary outcomes were at least a 50% reduction in the maximum width of cSDH on the last CT imaging, complications, and an improvement in the modified Rankin scale (mRS) score. All results were presented as descriptive statistics. Results A total of 209 MMA embolizations were successfully performed on 144 patients. Polyvinyl alcohol particles were the primary embolization agent in all procedures. Of the total of 206 cSDH, the median maximum width at pre-intervention and last follow-up were 12 and 3 mm, respectively, and the median reduction percentage was 77.5%, with a >50% improvement observed in 72.8% at the last follow-up imaging. A total of 13.8% of patients needed retreatment for recurrent, refractory, or symptomatic hematomas after embolization. The mRS score improved in 71 (49.3%) patients. Of 144 patients, 4 (2.8%) experienced complications related to the procedure, and 12 (8.4%) died during follow-up due to causes unrelated to the MMA embolization procedures. Conclusion This study supports the fact that MMA embolization without surgical evacuation is a safe and effective minimally invasive option for the treatment of cSDHs.
Collapse
Affiliation(s)
- Atakan Orscelik
- Department of Radiology, Mayo Clinic, Rochester, MN, United States
| | - Yigit Can Senol
- Department of Radiology, Mayo Clinic, Rochester, MN, United States
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Cem Bilgin
- Department of Radiology, Mayo Clinic, Rochester, MN, United States
| | - Hassan Kobeissi
- Department of Radiology, Mayo Clinic, Rochester, MN, United States
| | - Santhosh Arul
- Department of Radiology, Mayo Clinic, Rochester, MN, United States
| | - Harry Cloft
- Department of Radiology, Mayo Clinic, Rochester, MN, United States
| | - Giuseppe Lanzino
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, United States
| | - David F. Kallmes
- Department of Radiology, Mayo Clinic, Rochester, MN, United States
| | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic, Rochester, MN, United States
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, United States
| |
Collapse
|
10
|
Sioutas GS, Mannam SS, Corral Tarbay A, Nia AM, Salem MM, Vivanco-Suarez J, Burkhardt JK, Jankowitz BT, Srinivasan VM. Dexamethasone and Statins in Patients Undergoing Primary Middle Meningeal Artery Embolization for Chronic Subdural Hematoma: A Propensity-Matched Study in the TriNetX Research Network. World Neurosurg 2023; 176:e83-e90. [PMID: 37164211 DOI: 10.1016/j.wneu.2023.04.127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 04/28/2023] [Accepted: 04/29/2023] [Indexed: 05/12/2023]
Abstract
OBJECTIVE Middle meningeal artery embolization (MMAE) is an effective minimally invasive option for chronic subdural hematoma (cSDH). Dexamethasone and statins have been reported to improve the resolution of cSDH and reduce its recurrence. However, only 1 study has investigated the role of statins in patients treated with MMAE, and there is no such study on dexamethasone. Thus, we used the TriNetX research network to determine whether adding dexamethasone or statin along with primary MMAE is associated with a benefit in outcomes. METHODS We queried all primary MMAE cases for cSDH between January 1st, 2012, and July 1st, 2022, in the TriNetX research network. We included patients greater than or equal to 18 years old and separated them regarding statin and dexamethasone use around the time of MMAE. Outcomes were evaluated within 6 months and 3 years after MMAE, and analyses were performed before and after propensity score matching. RESULTS The study included 372 patients with chronic subdural hematoma who underwent MMAE and were on dexamethasone, 339 not on dexamethasone, 391 on statins, and 278 not on statins. After propensity score matching, the dexamethasone cohorts included 250 patients each and only headache remained more prevalent in the dexamethasone cohort at both 6 months (21.2% vs. 10.0%, P = 0.001) and 3 years (23.6% vs. 12.4%, P = 0.001). After propensity score matching, the statin cohorts included 150 patients each and no differences in outcomes were found at both 6 months and 3 months after MMAE. CONCLUSIONS Patients treated with primary MMAE and were on dexamethasone or statins had no differences in mortality and functional/provider dependence compared to those who were not on dexamethasone or statins. Patients on dexamethasone had a higher prevalence of headaches.
Collapse
Affiliation(s)
- Georgios S Sioutas
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Sneha Sai Mannam
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Antonio Corral Tarbay
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Anna M Nia
- Department of Neurological Surgery, Montefiore/Albert Einstein College of Medicine, Bronx, New York, USA
| | - Mohamed M Salem
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Juan Vivanco-Suarez
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Brian T Jankowitz
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA.
| |
Collapse
|
11
|
Liebert A, Voit-Höhne H, Ritter L, Eibl T, Hammer A, Städt M, Eff F, Holtmannspötter M, Steiner HH. Embolization of the middle meningeal artery vs. second surgery-treatment response and volume course of recurrent chronic subdural hematomas. Acta Neurochir (Wien) 2023:10.1007/s00701-023-05621-7. [PMID: 37247035 DOI: 10.1007/s00701-023-05621-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 05/05/2023] [Indexed: 05/30/2023]
Abstract
BACKGROUND Despite multiple studies on the embolization of the middle meningeal artery, there is limited data on the treatment response of recurrent chronic subdural hematomas (CSDH) to embolization and on the volume change. METHODS We retrospectively compared the treatment response and volume change of recurrent CSDHs in a conventional group (second surgery) with an embolization group (embolization as stand-alone treatment) during the time-period from August 2019 until June 2022. Different clinical and radiological factors were assessed. Treatment failure was defined as necessity of treatment for second recurrence. Hematoma volumes were determined in the initial CT scan before first surgery, after the first surgery, before retreatment as well as in an early (1 day-2 weeks) and in a late follow-up CT scan (2-8 weeks). RESULTS Fifty recurrent hematomas after initial surgery were treated either by second surgery (n = 27) or by embolization (n = 23). 8/27 (26,6%) surgically treated and 3/23 (13%) of the hematomas treated by embolization needed to be treated again. This leads to an efficacy in recurrent hematomas of 73,4% in surgically treated and of 87% in embolized hematomas (p = 0.189). In the conventional group, mean volume decreased significantly already in the first follow-up CT scan from 101.7 ml (SD 53.7) to 60.7 ml (SD 40.3) (p = 0.001) and dropped further in the later follow-up scan to 46.6 ml (SD 37.1) (p = 0.001). In the embolization group, the mean volume did decrease insignificantly from 75.1 ml (SD 27.3) to 68 ml (SD 31.4) in the first scan (p = 0.062). However, in the late scan significant volume reduction to 30.8 ml (SD 17.1) could be observed (p = 0.002). CONCLUSIONS Embolization of the middle meningeal artery is an effective treatment option for recurrent CSDH. Patients with mild symptoms who can tolerate slow volume reduction are suitable for embolization, whereas patients with severe symptoms should be reserved for surgery.
Collapse
Affiliation(s)
- Adrian Liebert
- Department of Neurosurgery, Paracelsus Medical University, Breslauer Straße 201, 90471, Nuremberg, Bavaria, Germany.
| | - Heinz Voit-Höhne
- Department of Neuroradiology, Paracelsus Medical University, Breslauer Straße 201, 90471, Nuremberg, Bavaria, Germany
| | - Leonard Ritter
- Department of Neurosurgery, Paracelsus Medical University, Breslauer Straße 201, 90471, Nuremberg, Bavaria, Germany
| | - Thomas Eibl
- Department of Neurosurgery, Paracelsus Medical University, Breslauer Straße 201, 90471, Nuremberg, Bavaria, Germany
| | - Alexander Hammer
- Department of Neurosurgery, Paracelsus Medical University, Breslauer Straße 201, 90471, Nuremberg, Bavaria, Germany
- Center for Spinal and Scoliosis Surgery, Malteser Waldkrankenhaus St. Marien, Erlangen, Bavaria, Germany
| | - Michael Städt
- Department of Neuroradiology, Paracelsus Medical University, Breslauer Straße 201, 90471, Nuremberg, Bavaria, Germany
| | - Florian Eff
- Department of Neuroradiology, Paracelsus Medical University, Breslauer Straße 201, 90471, Nuremberg, Bavaria, Germany
| | - Markus Holtmannspötter
- Department of Neuroradiology, Paracelsus Medical University, Breslauer Straße 201, 90471, Nuremberg, Bavaria, Germany
| | - Hans-Herbert Steiner
- Department of Neurosurgery, Paracelsus Medical University, Breslauer Straße 201, 90471, Nuremberg, Bavaria, Germany
| |
Collapse
|
12
|
Desir LL, Narayan V, Ellis J, Gordon D, Langer D, Ortiz R, Serulle Y. Middle Meningeal Artery Embolization in the Management of Chronic Subdural Hematoma: a Comprehensive Review of Current Literature. Curr Neurol Neurosci Rep 2023; 23:109-119. [PMID: 37037979 DOI: 10.1007/s11910-023-01262-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2023] [Indexed: 04/12/2023]
Abstract
PURPOSE OF REVIEW Chronic subdural hematoma (cSDH) is a common intracranial hemorrhagic disorder with a high incidence rate among the elderly. While small, asymptomatic cSDH may resolve spontaneously, surgical intervention has been the treatment of choice for larger, symptomatic cases. Surgical evacuation of cSDH may be associated with high rates of recurrence, and even asymptomatic cSDH cases tend to progress. Over the last few years, middle meningeal artery (MMA) embolization has proven to be a safe non-invasive treatment of choice with favorable outcomes and a low recurrence rate. The ensuing paper discusses current treatment modalities for cSDH and reviews existing literature on the anatomy of MMA and its embolization as a treatment option for cSDH. RECENT FINDINGS Recent studies show that traumatic head injury leading to subdural hemorrhage can induce neovascularization that may initiate a cycle of recurrent subdural hematoma. Distal branches of MMA supply blood to the dural layers. Several studies have revealed that embolization of the MMA can stop the neovascularization process and blood flow. In addition, patients who underwent MMA embolization had a significantly quicker brain re-expansion and lower recurrence rate. Although the management of cSDH is still very much a dilemma, recent research findings bring MMA embolization to light as a promising treatment alternative and adjunctive therapy.
Collapse
Affiliation(s)
- Likowsky L Desir
- Department of Neurosurgery, Lenox Hill Hospital, New York, NY, USA
- City University of New York School of Medicine, New York, NY, USA
| | - Vinayak Narayan
- Department of Neurosurgery, Lenox Hill Hospital, New York, NY, USA
| | - Jason Ellis
- Department of Neurosurgery, Lenox Hill Hospital, New York, NY, USA
| | - David Gordon
- Department of Neurosurgery, Lenox Hill Hospital, New York, NY, USA
| | - David Langer
- Department of Neurosurgery, Lenox Hill Hospital, New York, NY, USA
| | - Rafael Ortiz
- Department of Neurosurgery, Lenox Hill Hospital, New York, NY, USA
| | - Yafell Serulle
- Department of Neurosurgery, Lenox Hill Hospital, New York, NY, USA.
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.
- Neuroendovascular Surgery, Phelps Hospital, Sleepy Hollow, NY, USA.
| |
Collapse
|
13
|
Gillespie CS, Khanna S, Vivian ME, McKoy S, Yanez Touzet A, Edlmann E, Stubbs DJ, Davies BM. Is information provided within chronic subdural haematoma education resources adequate? A scoping review. PLoS One 2023; 18:e0283958. [PMID: 37023014 PMCID: PMC10079037 DOI: 10.1371/journal.pone.0283958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 03/21/2023] [Indexed: 04/07/2023] Open
Abstract
BACKGROUND Chronic subdural haematoma (CSDH) is becoming increasingly prevalent, due to an aging population with increasing risk factors. Due to its variable disease course and high morbidity, patient centred care and shared decision making are essential. However, its occurrence in frail populations, remote from specialist neurosurgeons who currently triage treatment decisions, challenges this. Education is an important component of enabling shared decisions. This should be targeted to avoid information overload. However, it is unknown what this should be. OBJECTIVES Our objectives were to conduct analysis of the content of existing CSDH educational materials, to inform the development of patient and relative educational resources to facilitate shared decision making. METHODS A literature search was conducted (July 2021) of MEDLINE, Embase and grey literature, for all self-specified resources on CSDH education, and narrative reviews. Resources were classified into a hierarchical framework using inductive thematic analysis into 8 core domains: Aetiology, epidemiology and pathophysiology; natural history and risk factors; symptoms; diagnosis; surgical management; nonsurgical management; complications and recurrence; and outcomes. Domain provision was summarised using descriptive statistics and Chi-squared tests. RESULTS 56 information resources were identified. 30 (54%) were resources designed for healthcare professionals (HCPs), and 26 (46%) were patient-orientated resources. 45 (80%) were specific to CSDH, 11 (20%) covered head injury, and 10 (18%) referenced both acute and chronic SDH. Of 8 core domains, the most reported were aetiology, epidemiology and pathophysiology (80%, n = 45) and surgical management (77%, n = 43). Patient orientated resources were more likely to provide information on symptoms (73% vs 13%, p<0.001); and diagnosis (62% vs 10%, p<0.001) when compared to HCP resources. Healthcare professional orientated resources were more likely to provide information on nonsurgical management (63% vs 35%, p = 0.032), and complications/recurrence (83% vs 42%, p = 0.001). CONCLUSION The content of educational resources is varied, even amongst those intended for the same audience. These discrepancies indicate an uncertain educational need, that will need to be resolved in order to better support effective shared decision making. The taxonomy created can inform future qualitative studies.
Collapse
Affiliation(s)
- Conor S. Gillespie
- Department of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
- The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - Samuel Khanna
- University Division of Anaesthesia, University of Cambridge, Cambridge, United Kingdom
| | - Mark E. Vivian
- University Division of Anaesthesia, University of Cambridge, Cambridge, United Kingdom
| | - Samuel McKoy
- The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
| | - Alvaro Yanez Touzet
- School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Ellie Edlmann
- Department of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Daniel J. Stubbs
- University Division of Anaesthesia, University of Cambridge, Cambridge, United Kingdom
| | - Benjamin M. Davies
- Department of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| |
Collapse
|
14
|
Development and validation of a recurrent prediction model for patients with unilateral chronic subdural hematoma without hematoma volumetric analysis. Clin Neurol Neurosurg 2023; 227:107678. [PMID: 36933403 DOI: 10.1016/j.clineuro.2023.107678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 03/11/2023] [Accepted: 03/14/2023] [Indexed: 03/18/2023]
Abstract
OBJECTIVE Approximately 10 % of patients with chronic subdural hematoma (CSDH) undergo reoperation after initial surgery. This study aimed to develop a predictive model for the recurrence of unilateral CSDH at initial surgery without hematoma volumetric analysis. METHODS This single-center retrospective cohort study evaluated pre- and postoperative computed tomography (CT) images of patients with unilateral CSDH. The pre- and postoperative midline shift (MLS), residual hematoma thickness, and subdural cavity thickness (SCT) were measured. CT images were classified based on the internal architecture of the hematoma (homogenous, laminar, trabecular, separated, and gradation subtypes). RESULTS Total 231 patients with unilateral CSDH underwent burr hole craniostomy. After receiver operating characteristic analysis, preoperative MLS and postoperative SCT showed better areas under the curve (AUCs) (0.684 and 0.756, respectively). According to the CT classification of preoperative hematomas, the recurrence rate was significantly higher in the separated/gradation group (18/97, 18.6 %) than in the homogenous/laminar/trabecular group (10/134, 7.5 %). Four-point score was derived from the multivariate model using the preoperative MLS, postoperative SCT, and CT classification. The AUC of this model was 0.796, and the recurrence rates at 0-4 points were 1.7 %, 3.2 %, 13.3 %, 25.0 %, and 35.7 %, respectively. CONCLUSION Pre- and postoperative CT findings without hematoma volumetric analysis may predict CSDH recurrence.
Collapse
|
15
|
Bartley A, Bartek J, Jakola AS, Sundblom J, Fält M, Förander P, Marklund N, Tisell M. Effect of Irrigation Fluid Temperature on Recurrence in the Evacuation of Chronic Subdural Hematoma: A Randomized Clinical Trial. JAMA Neurol 2023; 80:58-63. [PMID: 36409480 PMCID: PMC9679960 DOI: 10.1001/jamaneurol.2022.4133] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Importance The effect of a physical property of irrigation fluid (at body vs room temperature) on recurrence rate in the evacuation of chronic subdural hematoma (cSDH) needs further study. Objective To explore whether irrigation fluid temperature has an influence on cSDH recurrence. Design, Setting, and Participants This was a multicenter randomized clinical trial performed between March 16, 2016, and May 30, 2020. The follow-up period was 6 months. The study was conducted at 3 neurosurgical departments in Sweden. All patients older than 18 years undergoing cSDH evacuation during the study period were screened for eligibility in the study. Interventions The study participants were randomly assigned by 1:1 block randomization to the cSDH evacuation procedure with irrigation fluid at room temperature (RT group) or at body temperature (BT group). Main Outcomes and Measures The primary end point was recurrence requiring reoperation within 6 months. Secondary end points were mortality, health-related quality of life, and complication frequency. Results At 6 months after surgery, 541 patients (mean [SD] age, 75.8 [9.8] years; 395 men [73%]) had a complete follow-up according to protocol. There were 39 of 277 recurrences (14%) requiring reoperation in the RT group, compared with 16 of 264 recurrences (6%) in the BT group (odds ratio, 2.56; 95% CI, 1.38-4.66; P < .001). There were no significant differences in mortality, health-related quality of life, or complication frequency. Conclusions and Relevance In this study, irrigation at body temperature was superior to irrigation at room temperature in terms of fewer recurrences. This is a simple, safe, and readily available technique to optimize outcome in patients with cSDH. When irrigation is used in cSDH surgery, irrigation fluid at body temperature should be considered standard of care. Trial Registration ClincalTrials.gov Identifier: NCT02757235.
Collapse
Affiliation(s)
- Andreas Bartley
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, University of Gothenburg, Sahlgrenska Academy, Gothenburg, Sweden,Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jiri Bartek
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden,Department of Neurosurgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Asgeir S. Jakola
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, University of Gothenburg, Sahlgrenska Academy, Gothenburg, Sweden,Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jimmy Sundblom
- Department of Medical Sciences; Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Marie Fält
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Petter Förander
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Niklas Marklund
- Department of Clinical Sciences Lund, Neurosurgery, Lund University, Skåne University Hospital, Lund, Sweden
| | - Magnus Tisell
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, University of Gothenburg, Sahlgrenska Academy, Gothenburg, Sweden,Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| |
Collapse
|
16
|
Wang XJ, Yin YH, Wang ZF, Zhang Y, Sun C, Cui ZM. Efficacy evaluation of neuroendoscopy vs burr hole drainage in the treatment of chronic subdural hematoma: An observational study. World J Clin Cases 2022; 10:12920-12927. [PMID: 36568991 PMCID: PMC9782954 DOI: 10.12998/wjcc.v10.i35.12920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 10/01/2022] [Accepted: 11/17/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Chronic subdural hematoma (CSDH) is a common disease in neurosurgery. The traditional treatment methods include burr hole drainage, bone flap craniectomy and other surgical methods, and there are certain complications such as recurrence, pneumocephalus, infection and so on. With the promotion of neuroendoscopic technology, its treatment effect and advantages need to be further evaluated. AIM To study the clinical effect of endoscopic small-bone approach in CSDH. METHODS A total of 122 patients with CSDH admitted to our hospital from August 2018 to August 2021 were randomly divided into two groups using the digital table method: the neuroendoscopy group (n = 61 cases) and the burr hole drainage group (n = 61 cases). The clinical treatment effect of the two groups of patients with CSDH was compared. RESULTS At the early postoperative stage (1 d and 3 d), the proportion of 1/2 re-expansion of brain tissue in the hematoma cavity and the proportion of complete re-expansion was higher in the neuroendoscopy group than in the burr hole drainage group, and the difference between the two groups was statistically significant (P < 0.05). The recurrence rate of hematoma in the neuroendoscopy group was lower than that in the burr hole drainage group, and the difference between the two groups was statistically significant (P < 0.05). No intracranial hematoma, low cranial pressure, tension pneumocephalus or other complications occurred in the neuroendoscopy group. CONCLUSION The neuroendoscopic approach for the treatment of CSDH can clear the hematoma under direct vision and separate the mucosal lace-up. The surgical effect is apparent with few complications and definite curative effect, which is worthy of clinical promotion and application.
Collapse
Affiliation(s)
- Xue-Jian Wang
- Department of Neurosurgery, Affiliated Hospital 2 to Nantong University, Nantong 226001, Jiangsu Province, China
| | - Yu-Hua Yin
- Department of Neurosurgery, Renji Hospital, Shanghai Jiao Tong University, Shanghai 200000, China
| | - Zhi-Feng Wang
- Department of Neurosurgery, Affiliated Hospital 2 to Nantong University, Nantong 226001, Jiangsu Province, China
| | - Yi Zhang
- Department of Neurosurgery, Affiliated Hospital 2 to Nantong University, Nantong 226001, Jiangsu Province, China
| | - Cheng Sun
- Jiangsu Provincial Key Laboratory of Nerve Regeneration, Nantong University, Nantong 226001, Jiangsu Province, China
| | - Zhi-Ming Cui
- Department of Orthopedic, Affiliated Hospital 2 to Nantong University, Nantong 226001, Jiangsu Province, China
| |
Collapse
|
17
|
Mohamed S, Villabona A, Kennion O, Padmananbhan R, Siddiqui A, Khan S, Prasad M, Mukerji N. Middle meningeal artery embolisation for chronic subdural haematomas: the first prospective UK study. Br J Neurosurg 2022; 36:786-791. [PMID: 35892289 DOI: 10.1080/02688697.2022.2097200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Background/Objectives: MMA embolisation has emerged in recent years as a safe endovascular treatment for chronic subdural haematoma. We report the first UK series of endovascular treatment of chronic subdural haematomas.Design: Prospective case series.Subjects: All adult patients referred with midline shift ≤10 mm and GCS ≥13 were considered. Patients had to be mobile with a standard origin of Middle Meningeal and Ophthalmic arteries. Patients with GCS < 13 or profound weakness (MRC grade ≤ 3) were treated with burr hole drainage and placement of subdural drains.Methods: Patients were recruited over a 14-month period from 25 October 2020 to 25 December 21 through our electronic referral system. Patients' demographics, pre-morbid modified Rankin Score (mRS), symptoms; anticoagulation and co-morbidities were prospectively collected. Suitability for endovascular treatment was discussed with the interventional neuroradiologist and neurosurgeon. SQUID-12 embolic material was used for all MMA embolisations, which was performed under general anaesthetic. Baseline CT/MRI characteristics were collected. Further imaging was obtained at 7, 21, 90 and 180 days. Clinical assessment and mRS was completed at three months.Results: Fifteen patients underwent endovascular embolisation of MMA in the study period. Of these 13 were male, median age was 79 years. Median length of stay was four days. Follow-up CT at three months has demonstrated significant reduction in both midline shift (p = 0.002) and maximum thickness of haematoma (p = 0.001). Nine patients had reached the three months' follow-up period. All of them had complete or near-complete resolution of the CSDH. One patient required surgical rescue at two months post procedure due to progression of CSDH. We report one mortality due to COVID-19.Conclusions: For select patients, MMA embolisation is a safe alternative treatment option for chronic subdural haematoma. As we gain more experience, the procedure could be performed under local anaesthetic.
Collapse
Affiliation(s)
- Saffwan Mohamed
- Department of Neurosurgery, James Cook University Hospital, Middlesbrough, UK
| | - Alvaro Villabona
- Department of Neurosurgery, James Cook University Hospital, Middlesbrough, UK
| | - Oliver Kennion
- Department of Neurosurgery, James Cook University Hospital, Middlesbrough, UK
| | - Rajeev Padmananbhan
- Department of Neuroradiology, James Cook University Hospital, Middlesbrough, UK
| | - Aslam Siddiqui
- Department of Neuroradiology, James Cook University Hospital, Middlesbrough, UK
| | - Shahid Khan
- Department of Neurosurgery, James Cook University Hospital, Middlesbrough, UK
| | - Manjunath Prasad
- Department of Neurosurgery, James Cook University Hospital, Middlesbrough, UK
| | - Nitin Mukerji
- Department of Neurosurgery, James Cook University Hospital, Middlesbrough, UK
| |
Collapse
|
18
|
Atorvastatin Inhibits Ferroptosis of H9C2 Cells by regulatingSMAD7/Hepcidin Expression to Improve Ischemia-Reperfusion Injury. Cardiol Res Pract 2022; 2022:3972829. [PMID: 36398315 PMCID: PMC9666047 DOI: 10.1155/2022/3972829] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 10/27/2022] [Indexed: 11/09/2022] Open
Abstract
Background Ferroptosis plays a key role in cardiomyopathy. Atorvastatin (ATV) has a protective effect on ischemia-reperfusion (I/R) cardiomyopathy. The purpose of this study is to elucidate the mechanism of ATV in I/R injury. Methods H9C2 cells and cardiomyopathy rats were induced by hypoxia/reoxygenation (H/R) and I/R to construct in vitro and in vivo models. Cell viability was determined by CCK8. Cardiac histopathology was observed by HE staining. Transmission electron microscope (TEM) was used to observe the mitochondrial morphology. The reactive oxygen species (ROS) content in cells was analyzed by the biochemical method. ELISA was conducted to calculate the concentrations of total iron/Fe2+ and hepcidin. The expression of ferroptosis and SMAD pathway-related genes were detected by qPCR. Western blot was performed to detect the expression levels of ferroptosis and SMAD pathway-related proteins. Results In H9C2 cells, ATV reversed the decline in cell viability, mitochondrial shrinkage, and ROS elevation induced by erastin or H/R. The concentration of total iron and Fe2+ in H/R-induced H9C2 cells increased, and the protein expression of FPN1 decreased. After ATV treatment, the concentration of total iron and Fe2+ decreased, and the protein expression of FPN1 increased. The expression of the SMAD7 gene in H/R-induced H9C2 cells decreased, and the expression of the hepcidin gene increased, which were reversed by ATV. When SMAD7 was knocked down, ATV treatment failed to produce the above effect. ATV also improved ferroptosis in I/R rat myocardium through the SMAD7/hepcidin pathway. Conclusions ATV reversed the decline in H9C2 cell viability, mitochondrial shrinkage, and ROS elevation, and improved the myocardium ferroptosis through the SMAD7/hepcidin pathway in I/R rat.
Collapse
|
19
|
Surgery after primary dexamethasone treatment for patients with Chronic Subdural Hematoma - a retrospective study. World Neurosurg 2022; 162:e358-e368. [PMID: 35276391 DOI: 10.1016/j.wneu.2022.03.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 03/02/2022] [Accepted: 03/03/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND We aim to quantify the need for additional surgery in chronic subdural hematoma (CSDH) patients primarily treated with dexamethasone and to identify patient characteristics associated with additional surgery. METHOD Data were retrospectively collected from 283 CSDH patients, primarily treated with dexamethasone, in three hospitals from 2008 to 2018. Primary outcome was the need for additional surgery. The association between baseline characteristics and additional surgery was analyzed with univariable and multivariable logistic regression analysis and presented as adjusted odds ratios (aOR). RESULTS 283 CSDH patients were included. 146 patients (51.6%) received one dexamethasone course (DXM-group), 30 patients (10.6%) received two dexamethasone courses (DXM-DXM-group) and 107 patients (37.8%) received additional surgery (DXM-SURG-group). Patients who underwent surgery more often had a Markwalder Grading Scale of 2 (as compared to 1, aOR 2.05; 95% CI 0.90 - 4.65), used statins (aOR 2.09; 95% CI 1.01 - 4.33), a larger midline shift (aOR 1.10 per mm; 95% CI 1.01 - 1.21) and larger hematoma thickness (aOR 1.16 per mm; 95% CI 1.09 - 1.23), a bilateral hematoma (aOR 1.85; 95% CI 0.90 - 3.79) and a separated hematoma (as compared to homogeneous, aOR 1.77; 95% CI 0.72 - 4.38). Antithrombotics (aOR 0.45; 95% CI 0.21 - 0.95) and trabecular hematoma (as compared to homogeneous, aOR 0.31; 95% CI 0.12 - 0.77) were associated with a lower likelihood of surgery. CONCLUSION Over a third of CSDH patients primarily treated with dexamethasone received additional surgery. These patients were more severely affected amongst others with larger hematomas.
Collapse
|
20
|
Xu M, Tan W, Wang W, Wang D, Zeng W, Wang C. Minimally Invasive Surgery in Chronic Subdural Hematoma: Prognosis and Recurrence Factors of 516 Cases in a Single Center. J Clin Med 2022; 11:1321. [PMID: 35268412 PMCID: PMC8911056 DOI: 10.3390/jcm11051321] [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: 12/26/2021] [Revised: 02/12/2022] [Accepted: 02/22/2022] [Indexed: 11/19/2022] Open
Abstract
Objective: To investigate the effects of minimally invasive surgery (MIS) using a novel YL-1 puncture needle and summarize the risk factors of recurrence in chronic subdural hematoma (CSDH). Methods: We performed a retrospective analysis in 516 hospitalized patients with CSDH from January 2013 to December 2018 in Northern Jiangsu People’s Hospital. Patients’ gender, age, history of trauma, use of anticoagulants, history of disturbed liver or renal function, history of heart disease, history of malignant tumor, history of diabetes, hemodialysis, coagulopathy, alcoholism, imaging indicators, and postoperative application of urokinase or atorvastatin were recorded. Recurrence is defined by imaging examination with or without clinical presentation three months after discharge. Results: In total, 483 patients (93.60%) benefited from MIS by YL-1 needle. Gender, age, history of head trauma, history of disturbed liver function, history of heart disease, history of malignant tumor, history of diabetes, history of hemodialysis, coagulopathy, alcoholism, hematoma location, hematoma densities, septum formation, maximum thickness, encephalatrophy, and use of atorvastatin and urokinase were shown to be non-significantly associated with postoperative recurrence (p > 0.05). The use of anticoagulants was significantly associated with postoperative recurrence (p > 0. 05). Logistic analysis showed that the use of anticoagulants is an independent factor predicting postoperative recurrence (p > 0. 05). Conclusions: The novel YL-1 puncture needle turned out to be a safe and effective minimally invasive surgery, and the use of anticoagulants is an independent risk factor predicting postoperative recurrence in CSDH, which can provide MIS and early therapeutic strategies for neurosurgeons.
Collapse
Affiliation(s)
- Min Xu
- Department of Neurosurgery, Kunshan Hospital of Traditional Chinese Medicine (Kunshan Affiliated Hospital of Nanjing University of Chinese Medicine), Kunshan 215300, China; (M.X.); (W.T.); (W.W.)
| | - Weiguo Tan
- Department of Neurosurgery, Kunshan Hospital of Traditional Chinese Medicine (Kunshan Affiliated Hospital of Nanjing University of Chinese Medicine), Kunshan 215300, China; (M.X.); (W.T.); (W.W.)
| | - Wenhua Wang
- Department of Neurosurgery, Kunshan Hospital of Traditional Chinese Medicine (Kunshan Affiliated Hospital of Nanjing University of Chinese Medicine), Kunshan 215300, China; (M.X.); (W.T.); (W.W.)
| | - Dongdong Wang
- Department of Neurosurgery, Northern Jiangsu People’s Hospital, Yangzhou 225001, China; (D.W.); (W.Z.)
| | - Wei Zeng
- Department of Neurosurgery, Northern Jiangsu People’s Hospital, Yangzhou 225001, China; (D.W.); (W.Z.)
| | - Cunzu Wang
- Department of Neurosurgery, Northern Jiangsu People’s Hospital, Yangzhou 225001, China; (D.W.); (W.Z.)
| |
Collapse
|
21
|
Yang L, Li N, Yang L, Wang D, Qiang S, Zhao Z. Atorvastatin-Induced Absorption of Chronic Subdural Hematoma Is Partially Attributed to the Polarization of Macrophages. J Mol Neurosci 2021; 72:565-573. [PMID: 34569007 DOI: 10.1007/s12031-021-01910-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 09/02/2021] [Indexed: 11/25/2022]
Abstract
As one of the main types of secondary craniocerebral injury, the onset, progression, and prognosis of chronic subdural hematoma (CSDH) are closely related to the local inflammation of intracranial hematoma. Atorvastatin is reported to be effective in the conservative treatment of CSDH. This study aimed to clarify whether atorvastatin regulated the inflammatory responses in CSDH by interfering with the function of macrophages. The rat CSDH model was prepared by repeated intracranial blood injection with velocity gradient, and MRI was applied to calculate the intracranial hematoma volume. Changes in rat nerve functions were evaluated by foot-fault and Morris water maze tests. Flow cytometry was applied to detect the number of total macrophages and the percentage of M1 or M2 macrophages. The expression of inflammatory factors was examined by ELISA and western blot. Western bolt was applied to detect the expression of proteins involved in the colony-stimulating factor 1 receptor (CSF-1R) signaling pathway. Our results showed that atorvastatin significantly accelerated the absorption of hematoma and improved the nerve functions of CSDH rats. In addition, atorvastatin treatment effectively suppressed the expression of TNF-α, IL-6, and IL-8 and promoted the expression of IL-10. The total number of macrophages was decreased, and the percentage of M2 macrophages was increased in the intracranial hematoma following atorvastatin treatment. Furthermore, atorvastatin increased the levels of M2-related genes and surface markers in BMDMs stimulated by lipopolysaccharides and IFNγ, and activated the CSF-1R signaling pathway. In conclusion, our study shows that atorvastatin could alleviate the symptoms of CSDH and promote hematoma ablation by polarizing macrophages to M2 type and regulating the inflammatory responses.
Collapse
Affiliation(s)
- Liang Yang
- Department of Neurosurgery, the Second Hospital of Hebei Medical University, No. 215 Heping West Road, Shijiazhuang 050000, Hebei, China
| | - Nan Li
- Department of Gynecology, the Second Hospital of Hebei Medical University, No. 215 Heping West Road, Shijiazhuang 050000, Hebei, China
| | - Lijun Yang
- Department of Neurosurgery, the Second Hospital of Hebei Medical University, No. 215 Heping West Road, Shijiazhuang 050000, Hebei, China
| | - Dong Wang
- Department of Neurosurgery, Tianjin Medical University General Hospital, No. 154 Anshan Road, Tianjin, 300052, China
| | - Shuke Qiang
- Department of Neurosurgery, the Second Hospital of Hebei Medical University, No. 215 Heping West Road, Shijiazhuang 050000, Hebei, China
| | - Zongmao Zhao
- Department of Neurosurgery, the Second Hospital of Hebei Medical University, No. 215 Heping West Road, Shijiazhuang 050000, Hebei, China.
| |
Collapse
|
22
|
Zhang X, Wang D, Tian Y, Wei H, Liu X, Xiang T, Fan Y, Gao C, Huang J, Sha Z, Quan W, Zhang J, Jiang R. Risk Factors for Atorvastatin as a Monotherapy for Chronic Subdural Hematoma: A Retrospective Multifactor Analysis. Front Aging Neurosci 2021; 13:726592. [PMID: 34539386 PMCID: PMC8440973 DOI: 10.3389/fnagi.2021.726592] [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: 06/17/2021] [Accepted: 08/09/2021] [Indexed: 11/23/2022] Open
Abstract
Chronic subdural hematoma (CSDH) is a common form of intracranial hemorrhage in the aging population. We aimed to investigate the predictive factors for atorvastatin efficacy as a monotherapy for moderate CSDH. We retrospectively reviewed the medical records of patients who were diagnosed with moderate CSDH and received atorvastatin monotherapy between February 5, 2014, and November 7, 2015, in multiple neurosurgical departments. Univariate, multivariate and receiver operating characteristic curve analyses were performed to identify the potential significant factors indicative of the good therapeutic efficacy or poor therapeutic efficacy of atorvastatin for mild CSDH, such as age, sex, history of injury, Markwalder grading scale–Glasgow Coma Scale (MGS-GCS), Activities of Daily Life-the Barthel Index scale (ADL-BI), American Society of Anesthesiologists Physical Status classification system (ASA-PS), blood cell counts, serum levels and computed tomography findings. A total of 89 patients (75 men and 14 women) aged 24–88 years (mean age 61.95 ± 15.30 years) were followed-up for 24 weeks. Computed tomography findings at admission showed mixed-density hematoma in 22 patients, isodense hematoma in 13 patients, high-density hematoma in 26 patients, and low-density hematoma in 28 patients. In total, 3, 80, and 6 patients had MGS-GCS grades of 0, 1, and 2, respectively. The efficacy rate at 6 months was 87.6% (78/89). Eleven patients were switched to surgery due to a worsened neurological condition, of whom 8, 1, 1, and 1 had high-density, low-density, isodense and mixed-density hematomas, respectively. These patients were switched to surgery over a range of 2–27 days, with a median interval of 12 days after the medication treatment. Univariate and multivariate analyses, confirmed by ROC curves, revealed that high-density hematoma, basal cistern compression, and hematoma volume to be independent risk factors for the efficacy of atorvastatin monotherapy in patients with moderate CSDH. Atorvastatin is an effective monotherapy for the treatment of mild CSDH. High-density hematoma, basal cistern compression, and hematoma volume are independent predictors of the efficacy of atorvastatin as a non-surgical treatment. The results suggested that ADL-BI was more sensitive than the MGS-GCS and ASA-PS for determining patient outcomes in our moderate CSDH cohort.
Collapse
Affiliation(s)
- Xinjie Zhang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Dong Wang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Ye Tian
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Huijie Wei
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Xuanhui Liu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Tangtang Xiang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Yibing Fan
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Chuang Gao
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Jinhao Huang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Zhuang Sha
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Wei Quan
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Jianning Zhang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Rongcai Jiang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| |
Collapse
|
23
|
Lizana J, Aliaga N, Basurco A. Hematoma subdural crónico: Una patología común de manejo complejo. Surg Neurol Int 2021. [DOI: 10.25259/sni_676_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Antecedentes:
El hematoma subdural crónico (HSDC) es una patología ampliamente estudiada, muy frecuente, sobre todo en adultos mayores; su cuadro clínico tiene una apariencia benigna y suele ir acompañado de múltiples comorbilidades asociadas a la edad, lo que resulta en un aumento de las complicaciones e incluso la muerte. Con el incremento de la expectativa de vida a nivel mundial, el uso de medicamentos antitrombóticos es cada vez más frecuente. El papel de estos fármacos en la evolución de la enfermedad como en la recurrencia, sigue siendo motivo de discusión.
Métodos:
Los autores revisaron la fisiopatología y características clínicas del HSDC. El presente artículo discute acerca de las terapéuticas actuales y las nuevas opciones de tratamiento que podrían mejorar los resultados. Este manuscrito es susceptible de cambios en el tiempo, con el desarrollo científico y tecnológico.
Resultados:
El HSDC puede ser abordado por vía quirúrgica y farmacológica; no obstante, un manejo individualizado requiere la consideracion cuidadosa de diversos factores. A pesar de los avances en el campo de la neurocirugía, la clásica trepanación craneal sigue siendo el Gold estándar en el HSDC y sobre todo en pacientes con síntomas graves. Se debe resaltar que aún hay aspectos de este procedimiento (como la localización del dren, número de drenajes, el efecto de la irrigación, la temperatura de la solución con que se irriga, etc.) que siguen siendo materia de estudio.
Conclusiones:
Entender el mecanismo de la enfermedad ha permitido explicar su historia natural y a su vez proponer nuevas alternativas de tratamiento. El manejo médico (atorvastatina, corticoides) ha generado gran interés por sus alentadores resultados preliminares. Recientemente, se ha reportado la terapia endovascular como una alternativa segura y existe gran expectativa por confirmar su efecto en estudios más grandes.
Collapse
Affiliation(s)
- Jafeth Lizana
- Department of Neurosurgery, Hospital Nacional Guillermo Almenara, Lima, Peru,
| | - Nelida Aliaga
- Department of Medicine, School of Biomedical Sciences, Austral University, Mariano Acosta, Buenos Aires, Argentina
| | - Alfonso Basurco
- Department of Neurosurgery, Hospital Nacional Guillermo Almenara, Lima, Peru,
| |
Collapse
|
24
|
Wang X, Song J, He Q, You C. Pharmacological Treatment in the Management of Chronic Subdural Hematoma. Front Aging Neurosci 2021; 13:684501. [PMID: 34276343 PMCID: PMC8280518 DOI: 10.3389/fnagi.2021.684501] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 05/18/2021] [Indexed: 02/05/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Xing Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jinlei Song
- Department of Gastroenterology and Hepatology, West China Hospital, Sichuan University, Chengdu, China
| | - Qiang He
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
- Department of Neurosurgery, West China Brain Research Centre, Sichuan University, Chengdu, China
| |
Collapse
|
25
|
Onyinzo C, Berlis A, Abel M, Kudernatsch M, Maurer CJ. Efficacy and mid-term outcome of middle meningeal artery embolization with or without burr hole evacuation for chronic subdural hematoma compared with burr hole evacuation alone. J Neurointerv Surg 2021; 14:297-300. [PMID: 34187870 DOI: 10.1136/neurintsurg-2021-017450] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 06/14/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Chronic subdural hematoma (CSDH) is a common neurosurgical condition with high recurrence rates. Repeated microbleedings from fragile neo-vessels supplied by peripheral branches of the middle meningeal artery (MMA) are believed to be responsible for the growth and recurrence of CSDH. Thus, MMA embolization might be a promising method to prevent re-bleedings and recurrences. This study aims to assess the efficacy, complication rates, and mid-term outcome of MMA embolization with or without burr hole irrigation compared with burr hole irrigation alone. METHODS Patients diagnosed with CSDH who underwent MMA embolization and/or surgical treatment were retrospectively recruited to this single-center study. The outcome variables were defined as treatment-related complications, clinical outcome at discharge, rate of revision surgery, and CT findings during the follow-up period. RESULTS A total of 132 patients with CSDH were included in the study. The use of antiplatelet/anticoagulant medication was significantly higher in the combined treatment and embolization group (p<0.001). A trend towards fewer revision surgeries was found in the group of patients who received MMA embolization combined with burr hole irrigation (p=0.083). Follow-up was available for 73 patients (55.3%) with a mean follow-up period of 3.4±2.2 months. Eight patients (15.1%) of the surgery group showed hematoma re-accumulation and needed surgical rescue, whereas only one patient (5.0%) of the combined treatment group needed revision surgery. In all patients treated with only MMA embolization, complete hematoma resolution was found. CONCLUSION MMA embolization is a safe and efficacious minimal invasive adjuvant and/or alternative procedure for the treatment of CSDH with a reduced recurrence rate.
Collapse
Affiliation(s)
- Christina Onyinzo
- Department of Neurosurgery, Schoen Clinic Vogtareuth, Vogtareuth, Bavaria, Germany
| | - Ansgar Berlis
- Department of Diagnostic and Interventionell Radiology and Neuroradiology, University Hospital Augsburg, Augsburg, Bavaria, Germany.,Department of Neuroradiology, Schoen Clinic Vogtareuth, Vogtareuth, Bavaria, Germany
| | - Maria Abel
- Department of Neurosurgery, Schoen Clinic Vogtareuth, Vogtareuth, Bavaria, Germany
| | - Manfred Kudernatsch
- Department of Neurosurgery, Schoen Clinic Vogtareuth, Vogtareuth, Bavaria, Germany.,Research Institute Rehabilitation, Transition, Palliation, Paracelsus Medizinische Privatuniversität, Salzburg, Austria
| | - Christoph J Maurer
- Department of Diagnostic and Interventionell Radiology and Neuroradiology, University Hospital Augsburg, Augsburg, Bavaria, Germany.,Department of Neuroradiology, Schoen Clinic Vogtareuth, Vogtareuth, Bavaria, Germany
| |
Collapse
|
26
|
Honda M, Maeda H. Intraoperative hematoma volume can predict chronic subdural hematoma recurrence. Surg Neurol Int 2021; 12:232. [PMID: 34221563 PMCID: PMC8247721 DOI: 10.25259/sni_97_2021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 04/20/2021] [Indexed: 11/17/2022] Open
Abstract
Background: We routinely measured the exact chronic subdural hematoma (CSDH) volume during single burr hole surgery. To date, several risk factors have been reported for CSDH recurrence, including sex, hematoma volume and degree of midline shift calculated from computed tomography, use of anticoagulants or antiplatelet medications, and alcohol consumption habits. The aim of this study was to clarify whether hematoma volume, in conjunction with other factors, can predict recurrence. Methods: We retrospectively reviewed the clinical data of 194 consecutive patients with CSDH who underwent single burr hole surgery. The risk factors for recurrence were analyzed based on patients’ sex, age, bilaterality, existence of apparent trauma history, exact intraoperative hematoma volume, and various clinical factors, including preoperative anticoagulant/antiplatelet intake. Results: Recurrence occurred in 22 patients (11.3%). Multivariate logistic regression analysis revealed that intraoperative hematoma volume was an independent risk factor for CSDH recurrence (odds ratio [OR], 1.01; 95% confidence interval [CI], 1.01–1.02, P < 0.001), in addition to sex (male) (OR 9.25; 95% CI, 1.00–84.8; P = 0.049) and diabetes mellitus (DM) (OR: 3.97, 95% CI, 1.34–11.7, P = 0.013). Based on receiver operating characteristics analysis, the cutoff value of the hematoma volume predicting CSDH recurrence was 150 ml (sensitivity and specificity of 72.7% and 72.1%, respectively; area under the curve: 0.7664, 95% CI: 0.654–0.879, P < 0.001). Of these, a hematoma volume ≥150 mL was the strongest independent risk factor for recurrence according to multiple regression (OR: 8.98, 95% CI: 2.73–29.6, P < 0.001) and Cox regression analysis (hazard ratio: 3.05, 95% CI: 1.18–7.87, log-rank P = 0.0046, P = 0.021). Follow-up periods after surgery were significantly longer for cases with recurrence than for non-recurrence cases (24.8 ± 11.5 vs. 15.9 ± 9.7 days), and the recurrence prediction cutoff value was 17 days, with a sensitivity and specificity of 83.1% and 68.2%, respectively (AUC: 0.7707, 95% CI: 0.6695–0.8720, P < 0.001). Conclusion: Intraoperative hematoma volume could be a predictive value for CSDH recurrence.
Collapse
Affiliation(s)
- Masaru Honda
- Department of Neurosurgery, Shunan Memorial Hospital, Kudamatsu, Yamaguchi, Japan
| | - Hajime Maeda
- Department of Neurosurgery, Shunan Memorial Hospital, Kudamatsu, Yamaguchi, Japan
| |
Collapse
|
27
|
Takei J, Hirotsu T, Hatano K, Ishibashi T, Inomata T, Noda Y, Morooka S, Murayama Y. Modified Computed Tomography Classification for Chronic Subdural Hematoma Features Good Interrater Agreement: A Single-Center Retrospective Cohort Study. World Neurosurg 2021; 151:e407-e417. [PMID: 33892165 DOI: 10.1016/j.wneu.2021.04.052] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/11/2021] [Accepted: 04/12/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The present study aimed to establish whether our modified Nakaguchi computed tomography (CT) classification improves the interrater agreement of chronic subdural hematoma (CSDH) classification and prediction of CSDH recurrence relative to 2 other CT classifications. METHODS This retrospective study considered 277 consecutive patients with CSDH and 307 hematomas treated with burr-hole surgery between January 2009 and December 2018. Two neurosurgeons blinded to patients' clinical data classified the CT scans of patients with CSDH into 4 or 5 types according to the Nomura classification (high, iso, low, mixed, and layering), Nakaguchi classification (homogenous, laminar, separated, and trabecular), and our modified Nakaguchi classification (homogenous, gradation, laminar, separated, and trabecular). The κ statistic was used to evaluate the interrater agreement of the 3 CT classifications. Univariable and multivariable logistic regression analyses were used to calculate odds ratios for CSDH recurrence. RESULTS κ values of the modified, Nakaguchi, and Nomura classification were 0.78, 0.63, and 0.70, respectively. During the 3 months follow-up, the recurrence rate for CSDH was 11.4% (35/307 hematomas). Of the types defined by the modified classification, the gradation type was associated with the highest recurrence (mean recurrence rate, 15.9% ± 0.3%). Multivariable logistic regression analyses showed that a gradation-type hematoma, as defined with the modified classification, was an independent risk factor associated with recurrence (odds ratio, 2.36; 95% confidence interval, 1.11-4.98; P = 0.025). CONCLUSIONS The modified classification was useful for preoperative CT classification of CSDH and the prediction of recurrence, with high agreement between raters.
Collapse
Affiliation(s)
- Jun Takei
- Department of Neurosurgery, Fuji City General Hospital, Fuji, Shizuoka, Japan; Department of Neurosurgery, Jikei University School of Medicine, Minato-ku, Tokyo, Japan.
| | - Tatsuya Hirotsu
- Department of Neurosurgery, Jikei University School of Medicine, Minato-ku, Tokyo, Japan
| | - Keisuke Hatano
- Department of Neurosurgery, Jikei University School of Medicine, Minato-ku, Tokyo, Japan
| | - Toshihiro Ishibashi
- Department of Neurosurgery, Jikei University School of Medicine, Minato-ku, Tokyo, Japan
| | - Takayuki Inomata
- Department of Radiology, Fuji City General Hospital, Fuji, Shizuoka, Japan
| | - Yasuto Noda
- Department of Neurosurgery, Fuji City General Hospital, Fuji, Shizuoka, Japan
| | - Satoru Morooka
- Department of Neurosurgery, Fuji City General Hospital, Fuji, Shizuoka, Japan
| | - Yuichi Murayama
- Department of Neurosurgery, Jikei University School of Medicine, Minato-ku, Tokyo, Japan
| |
Collapse
|
28
|
Kan P, Maragkos GA, Srivatsan A, Srinivasan V, Johnson J, Burkhardt JK, Robinson TM, Salem MM, Chen S, Riina HA, Tanweer O, Levy EI, Spiotta AM, Kasab SA, Lena J, Gross BA, Cherian J, Cawley CM, Howard BM, Khalessi AA, Pandey AS, Ringer AJ, Hanel R, Ortiz RA, Langer D, Kelly CM, Jankowitz BT, Ogilvy CS, Moore JM, Levitt MR, Binning M, Grandhi R, Siddiq F, Thomas AJ. Middle Meningeal Artery Embolization for Chronic Subdural Hematoma: A Multi-Center Experience of 154 Consecutive Embolizations. Neurosurgery 2021; 88:268-277. [PMID: 33026434 DOI: 10.1093/neuros/nyaa379] [Citation(s) in RCA: 113] [Impact Index Per Article: 37.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 06/27/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Middle meningeal artery (MMA) embolization has emerged as a promising treatment for chronic subdural hematoma (cSDH). OBJECTIVE To determine the safety and efficacy of MMA embolization. METHODS Consecutive patients who underwent MMA embolization for cSDH (primary treatment or recurrence after conventional surgery) at 15 centers were included. Clinical details and follow-up were collected prospectively. Primary clinical and radiographic outcomes were the proportion of patients requiring additional surgical treatment within 90 d after index treatment and proportion with > 50% cSDH thickness reduction on follow-up computed tomography imaging within 90 d. National Institute of Health Stroke Scale and modified Rankin Scale were also clinical outcomes. RESULTS A total of 138 patients were included (mean age: 69.8, 29% female). A total of 15 patients underwent bilateral interventions for 154 total embolizations (66.7% primary treatment). At presentation, 30.4% and 23.9% of patients were on antiplatelet and anticoagulation therapy, respectively. Median admission cSDH thickness was 14 mm. A total of 46.1% of embolizations were performed under general anesthesia, and 97.4% of procedures were successfully completed. A total of 70.2% of embolizations used particles, and 25.3% used liquid embolics with no significant outcome difference between embolization materials (P > .05). On last follow-up (mean 94.9 d), median cSDH thickness was 4 mm (71% median thickness reduction). A total of 70.8% of patients had >50% improvement on imaging (31.9% improved clinically), and 9 patients (6.5%) required further cSDH treatment. There were 16 complications with 9 (6.5%) because of continued hematoma expansion. Mortality rate was 4.4%, mostly unrelated to the index procedure but because of underlying comorbidities. CONCLUSION MMA embolization may provide a safe and efficacious minimally invasive alternative to conventional surgical techniques.
Collapse
Affiliation(s)
- Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Georgios A Maragkos
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Aditya Srivatsan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Visish Srinivasan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Jeremiah Johnson
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | | | - Timothy M Robinson
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Mohamed M Salem
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Stephen Chen
- Department of Radiology, Baylor College of Medicine, Houston, Texas
| | - Howard A Riina
- Department of Neurosurgery, NYU Langone Medical Center, New York City, New York
| | - Omar Tanweer
- Department of Neurosurgery, NYU Langone Medical Center, New York City, New York
| | - Elad I Levy
- Department of Neurosurgery, University at Buffalo, State University of New York, Buffalo, New York
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical College of South Carolina, Charleston, South Carolina
| | - Sami Al Kasab
- Department of Neurosurgery, Medical College of South Carolina, Charleston, South Carolina
| | - Jonathan Lena
- Department of Neurosurgery, Medical College of South Carolina, Charleston, South Carolina
| | - Bradley A Gross
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jacob Cherian
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - C Michael Cawley
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Brian M Howard
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Alexander A Khalessi
- Department of Neurosurgery, University of California, San Diego, La Jolla, California
| | - Aditya S Pandey
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Andrew J Ringer
- Mayfield Clinic, TriHealth Neuroscience Institute, Good Samaritan Hospital, Cincinnati, Ohio
| | - Ricardo Hanel
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida
| | - Rafael A Ortiz
- Department of Neurosurgery, Lenox Hill Hospital, New York City, New York
| | - David Langer
- Department of Neurosurgery, Lenox Hill Hospital, New York City, New York
| | - Cory M Kelly
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | | | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Justin M Moore
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Michael R Levitt
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Mandy Binning
- Department of Neurosurgery, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Ramesh Grandhi
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Farhan Siddiq
- Department of Neurosurgery, University of Missouri, Columbia, Montana
| | - Ajith J Thomas
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
29
|
Guidry BS, Kelly KA, Yengo-Kahn AM, Lan M, Tang AR, Chotai S, Morone P, Kelly PD. Statins as a Medical Adjunct in the Surgical Management of Chronic Subdural Hematomas. World Neurosurg 2021; 149:e281-e291. [PMID: 33610873 DOI: 10.1016/j.wneu.2021.02.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 02/08/2021] [Accepted: 02/09/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND By stabilizing immature leaky vessel formation in neomembranes, statin drugs have been suggested as a nonsurgical treatment option for chronic subdural hematomas (cSDH). Statin therapy seems to reduce conservatively managed cSDH volume. However, the usefulness of these medications in supplementing surgical treatment is unknown. OBJECTIVE To investigate the effect of concurrent statin therapy on outcomes after surgical treatment of cSDH. METHODS A retrospective single-institution cohort study of surgically managed patients with convexity cSDH between 2009 and 2019 was conducted. Patients receiving this diagnosis who underwent surgical decompression were included, and those without follow-up scans were excluded. Demographic, clinical, and radiographic variables were collected. cSDH size was defined as maximum radial thickness in millimeters on axial computed tomography of the head. Multivariable linear regression was performed to identify factors (including statin use) that were associated with preoperative to follow-up cSDH size change. RESULTS Overall, 111 patients, including 36 patients taking statins on admission, were evaluated. Median time to follow-up postoperative imaging was 30 days (interquartile range, 17-42 days). Patients on statins were older (median, 75 years, range, 68-78.25 years vs. 69 years, range, 59-7 years; P = 0.006) and reported more antiplatelet use (67% vs. 28%; P < 0.001). Median change in follow-up size was 13 mm in both statin and nonstatin groups. Adjusting for other clinical covariates, statin use was associated with greater reduction in cSDH size (CE = -6.72 mm, 95% confidence interval, -13.18 to -0.26 mm; P = 0.042). CONCLUSIONS Statin use is associated with improved cSDH size postoperatively. Statin drugs might represent a low-cost and low-risk supplement to the surgical management for patients with cSDH.
Collapse
Affiliation(s)
- Bradley S Guidry
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | | | - Aaron M Yengo-Kahn
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Matthews Lan
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Alan R Tang
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Silky Chotai
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Peter Morone
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Patrick D Kelly
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
| |
Collapse
|
30
|
Wang D, Wang H, Xu M, Chen P, Yu B, Wen J, Zhang H, Zeng W, He S, Wang C. The effect of atorvastatin on recurrence of chronic subdural hematoma after novel YL-1 puncture needle surgery. Clin Neurol Neurosurg 2021; 202:106548. [PMID: 33609954 DOI: 10.1016/j.clineuro.2021.106548] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 02/01/2021] [Accepted: 02/02/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Chronic subdural hematoma (CSDH) is a common neurological disorder with a high recurrence rate. This study investigates the effect that atorvastatin has when used as a postoperative adjuvant therapy on the prevention of CSDH recurrence after YL-1 puncture needle surgery. PATIENTS AND METHODS A retrospective analysis of 516 CSDH patients who underwent YL-1 puncture needle surgery was undertaken. Baseline characteristics including sex, age, history of injury, past medical histories (anticoagulation, liver dysfunction, heart diseases, malignant tumors, diabetes, hemodialysis, and chronic alcoholism), and computed tomography (CT) or magnetic resonance imaging (MRI) diagnostic indicators (bilateral, mixed density or signal, maximum hematoma width, and brain atrophy) were recorded. Differences in recurrence rates were compared between two groups: one with atorvastatin after surgery and one without. RESULTS 516 patients (429 men and 87 women), aged 14-98 years (mean age, 67.09 ± 11.74 years) were included in the study. YL-1 puncture needle surgery was performed 610 times. 94 patients had bilateral surgery, totaling 184 procedures. 301 patients with 360 procedures were treated with atorvastatin after surgery, of which 25 had recurrent CSDH; recurrence rate: 7.0 % (25/360). 215 patients with 250 procedures had surgery without subsequent atorvastatin, of which 14 had recurrent CSDH; recurrence rate: 5.6 % (14/250). Univariate analysis indicated no statistically significant difference in recurrence rates between groups (P > 0.05). Baseline characteristics of the two groups (age, sex, history of injury, past medical histories, CT or MRI diagnostic indicators) also showed no statistical difference (all P > 0.05). CONCLUSIONS YL-1 puncture needle surgery with irrigation and closed-system drainage is an effective surgical treatment for CSDH. Atorvastatin has no statistically significant effect on the prevention of CSDH recurrence after surgery.
Collapse
Affiliation(s)
- Dongdong Wang
- School of Clinical Medicine, Dalian Medical University, 9 West Section, Lvshun South Road, Dalian, Liaoning Province, 116000, China; Department of Neurosurgery, Northern Jiangsu People's Hospital, Clinical Medical College, Yangzhou University, 98 Nantong West Road, Yangzhou, Jiangsu Province, 225001, China
| | - Hui Wang
- School of Clinical Medicine, Dalian Medical University, 9 West Section, Lvshun South Road, Dalian, Liaoning Province, 116000, China; Department of Neurosurgery, Northern Jiangsu People's Hospital, Clinical Medical College, Yangzhou University, 98 Nantong West Road, Yangzhou, Jiangsu Province, 225001, China
| | - Min Xu
- Department of Neurosurgery, Traditional Chinese Medicine Hospital of Kunshan, Kunshan Affiliated Hospital of Nanjing University of Chinese Medicine, 189 Chaoyang Road, Kunshan, Jiangsu Province, 215300, China
| | - Pin Chen
- Department of Neurosurgery, Northern Jiangsu People's Hospital, Clinical Medical College, Yangzhou University, 98 Nantong West Road, Yangzhou, Jiangsu Province, 225001, China
| | - Bo Yu
- Department of Neurosurgery, Northern Jiangsu People's Hospital, Clinical Medical College, Yangzhou University, 98 Nantong West Road, Yangzhou, Jiangsu Province, 225001, China
| | - Jinkun Wen
- Department of Neurosurgery, Northern Jiangsu People's Hospital, Clinical Medical College, Yangzhou University, 98 Nantong West Road, Yangzhou, Jiangsu Province, 225001, China
| | - Hengzhu Zhang
- Department of Neurosurgery, Northern Jiangsu People's Hospital, Clinical Medical College, Yangzhou University, 98 Nantong West Road, Yangzhou, Jiangsu Province, 225001, China
| | - Wei Zeng
- Department of Neurosurgery, Northern Jiangsu People's Hospital, Clinical Medical College, Yangzhou University, 98 Nantong West Road, Yangzhou, Jiangsu Province, 225001, China
| | - Shiwei He
- School of Clinical Medicine, Dalian Medical University, 9 West Section, Lvshun South Road, Dalian, Liaoning Province, 116000, China; Department of Neurosurgery, Northern Jiangsu People's Hospital, Clinical Medical College, Yangzhou University, 98 Nantong West Road, Yangzhou, Jiangsu Province, 225001, China
| | - Cunzu Wang
- Department of Neurosurgery, Northern Jiangsu People's Hospital, Clinical Medical College, Yangzhou University, 98 Nantong West Road, Yangzhou, Jiangsu Province, 225001, China.
| |
Collapse
|
31
|
Takei J, Tanaka T, Yamamoto Y, Hatano K, Ichinose D, Maruyama F, Tochigi S, Hasegawa Y, Murayama Y. Significantly high concentrations of vascular endothelial growth factor in chronic subdural hematoma with trabecular formation. Clin Neurol Neurosurg 2021; 202:106458. [PMID: 33545457 DOI: 10.1016/j.clineuro.2020.106458] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 12/25/2020] [Accepted: 12/26/2020] [Indexed: 10/22/2022]
Abstract
The underlying mechanism of chronic subdural hematoma (CSDH) after minor head injury is complex, probably due to mechanical injury of the arachnoid membrane, hematological coagulopathy, and pathological angiogenesis in the dura caused by inflammatory cytokines including vascular endothelial growth factor (VEGF). To confirm whether VEGF might be a reliable predictive biomarker for the natural history of CSDH, including progression and recurrence, we analyzed the correlation of VEGF concentration in the subdural fluid with CT findings and clinical features, including interval from minor head injury. Based on CT classification by hematoma density, the mean concentration of VEGF in hematoma fluid was found to be highest in the trabecular group, whereas the recurrence of CSDH was most frequent in the separated group in which VEGF concentration was low. There was a significant correlation between VEGF concentration and the CT classification. Furthermore, only in the trabecular group, a significant negative correlation between the VEGF concentration and interval from minor head injury to surgery was observed. These results suggest that VEGF concentration in the hematoma alone could not be a reliable predictive biomarker for the natural history of CSDH including its recurrence. Amongst the classified groups of CSDH, the trabecular group is likely to follow a different time course of VEGF concentration in the hematoma fluid compared to the other three groups.
Collapse
Affiliation(s)
- Jun Takei
- Department of Neurosurgery, Jikei University School of Medicine Kashiwa Hospital, Japan; Department of Neurosurgery, Jikei University School of Medicine, Japan
| | - Toshihide Tanaka
- Department of Neurosurgery, Jikei University School of Medicine Kashiwa Hospital, Japan.
| | - Yohei Yamamoto
- Department of Neurosurgery, Jikei University School of Medicine Kashiwa Hospital, Japan
| | - Keisuke Hatano
- Department of Neurosurgery, Jikei University School of Medicine, Japan
| | - Diasuke Ichinose
- Department of Neurosurgery, Jikei University School of Medicine, Japan
| | - Fumiaki Maruyama
- Department of Neurosurgery, Jikei University School of Medicine, Japan
| | - Satoru Tochigi
- Department of Neurosurgery, Jikei University School of Medicine Kashiwa Hospital, Japan
| | - Yuzuru Hasegawa
- Department of Neurosurgery, Jikei University School of Medicine Kashiwa Hospital, Japan
| | - Yuichi Murayama
- Department of Neurosurgery, Jikei University School of Medicine, Japan
| |
Collapse
|
32
|
Martinez-Perez R, Rayo N, Tsimpas A. Endovascular embolisation of the middle meningeal artery to treat chronic subdural haematomas: effectiveness, safety, and the current controversy. A systematic review. NEUROLOGÍA (ENGLISH EDITION) 2021; 38:124-130. [PMID: 36990626 DOI: 10.1016/j.nrleng.2020.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 04/12/2020] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Chronic subdural haematoma (CSDH) represents a clinical challenge due to its high recurrence rate. Endovascular middle meningeal artery embolisation (eMMAE) has emerged as an alternative for those patients presenting health problems or multiple recurrences of CSDH. Despite several encouraging reports, the safety profile, indications, and limitations of the technique are not clearly established. DEVELOPMENT This study aimed to evaluate the current evidence on eMMAE in patients with CSDH. We performed a systematic review of the literature, following the PRISMA guidelines. Our search yielded a total of 6 studies, in which a total of 164 patients with CSDH underwent eMMAE. The recurrence rate across all studies was 6.7%, and complications occurred in up to 6% of patients. CONCLUSIONS eMMAE is a feasible technique for treating CSDH, with a relatively low recurrence rate and an acceptable rate of complications. Further prospective and randomised studies are needed to formally establish a clear profile of the safety and effectiveness of the technique.
Collapse
|
33
|
Wang D, Gao C, Xu X, Chen T, Tian Y, Wei H, Zhang S, Quan W, Wang Y, Yue S, Wang Z, Lei P, Anderson C, Dong J, Zhang J, Jiang R. Treatment of chronic subdural hematoma with atorvastatin combined with low-dose dexamethasone: phase II randomized proof-of-concept clinical trial. J Neurosurg 2021; 134:235-243. [PMID: 32005012 DOI: 10.3171/2019.11.jns192020] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 11/18/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors sought to test the hypothesis that adding dexamethasone (DXM) to atorvastatin (ATO) potentiates the effects of ATO on chronic subdural hematoma (CSDH). METHODS Sixty patients with CSDH underwent 5 weeks of treatment with an additional 7-week follow-up. Patients were randomized to receive a 5-week regimen of ATO 20 mg daily or ATO 20 mg daily plus a DXM regimen (ATO+DXM). The 5-week DXM regimen was 2.25 mg daily for 2 consecutive weeks, followed by 0.75 mg twice daily for 2 weeks and 0.75 mg once daily for 1 week. The primary endpoint was hematoma reduction assessed by neuroimaging at baseline and at 5 weeks of follow-up. Secondary outcomes included neurological improvement assessed by using the Markwalder's Grading Scale and Glasgow Coma Scale (MGS-GCS). RESULTS The mean patient age was 66.6 years, and 25% of patients were women. The patients who were treated with ATO+DXM had more obvious hematoma reduction at the 5th week (between-groups difference 18.37 ml; 95% CI 8.17-28.57; p = 0.0005). This reduction started from the 2nd week (14.51 ml; 95% CI 4.31-24.71; p = 0.0056) of treatment and persisted until the 12th week (17.50 ml; 95% CI 7.30-27.70; p = 0.0009). Complete recovery of neurological function (MGS-GCS grade 0) at 5 weeks was achieved in 83.33% and 32.14% of patients in the ATO+DXM and ATO groups, respectively. At the 5th week, patients receiving ATO+DXM had significantly lower levels of T cells and higher levels of regulatory T cells and endothelial progenitor cells in their peripheral blood. CONCLUSIONS ATO+DXM was more effective than ATO alone in reducing hematoma and improving neurological function in patients with CSDH. These results require further confirmation in a randomized placebo-controlled trial.Clinical trial registration no.: ChiCTR-IPR-14005573 (http://www.chictr.org.cn/index.aspx).
Collapse
Affiliation(s)
- Dong Wang
- 1Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin
- 2Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in the Central Nervous System, Ministry of Education, Tianjin Medical University, Tianjin Key Laboratory of Injury and Regenerative Medicine of Nervous System, Tianjin Neurological Institute, Tianjin, China
| | - Chuang Gao
- 1Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin
- 2Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in the Central Nervous System, Ministry of Education, Tianjin Medical University, Tianjin Key Laboratory of Injury and Regenerative Medicine of Nervous System, Tianjin Neurological Institute, Tianjin, China
| | - Xin Xu
- 1Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin
- 2Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in the Central Nervous System, Ministry of Education, Tianjin Medical University, Tianjin Key Laboratory of Injury and Regenerative Medicine of Nervous System, Tianjin Neurological Institute, Tianjin, China
| | - Tao Chen
- 3Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Ye Tian
- 1Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin
- 2Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in the Central Nervous System, Ministry of Education, Tianjin Medical University, Tianjin Key Laboratory of Injury and Regenerative Medicine of Nervous System, Tianjin Neurological Institute, Tianjin, China
| | - Huijie Wei
- 1Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin
- 2Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in the Central Nervous System, Ministry of Education, Tianjin Medical University, Tianjin Key Laboratory of Injury and Regenerative Medicine of Nervous System, Tianjin Neurological Institute, Tianjin, China
| | - Shu Zhang
- 2Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in the Central Nervous System, Ministry of Education, Tianjin Medical University, Tianjin Key Laboratory of Injury and Regenerative Medicine of Nervous System, Tianjin Neurological Institute, Tianjin, China
| | - Wei Quan
- 1Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin
- 2Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in the Central Nervous System, Ministry of Education, Tianjin Medical University, Tianjin Key Laboratory of Injury and Regenerative Medicine of Nervous System, Tianjin Neurological Institute, Tianjin, China
| | - Yi Wang
- 1Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin
- 2Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in the Central Nervous System, Ministry of Education, Tianjin Medical University, Tianjin Key Laboratory of Injury and Regenerative Medicine of Nervous System, Tianjin Neurological Institute, Tianjin, China
| | - Shuyuan Yue
- 1Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin
- 2Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in the Central Nervous System, Ministry of Education, Tianjin Medical University, Tianjin Key Laboratory of Injury and Regenerative Medicine of Nervous System, Tianjin Neurological Institute, Tianjin, China
| | - Zengguang Wang
- 1Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin
- 2Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in the Central Nervous System, Ministry of Education, Tianjin Medical University, Tianjin Key Laboratory of Injury and Regenerative Medicine of Nervous System, Tianjin Neurological Institute, Tianjin, China
| | - Ping Lei
- 4Department of Geriatrics, Tianjin Medical University General Hospital, Tianjin, China
| | - Craig Anderson
- 5George Institute China at Peking University Health Science Center China and George Institute for International Health, University of Sydney, Australia; and
| | - Jingfei Dong
- 6Bloodworks Research Institute, Bloodworks Northwest and Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Jianning Zhang
- 1Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin
- 2Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in the Central Nervous System, Ministry of Education, Tianjin Medical University, Tianjin Key Laboratory of Injury and Regenerative Medicine of Nervous System, Tianjin Neurological Institute, Tianjin, China
| | - Rongcai Jiang
- 1Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin
- 2Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in the Central Nervous System, Ministry of Education, Tianjin Medical University, Tianjin Key Laboratory of Injury and Regenerative Medicine of Nervous System, Tianjin Neurological Institute, Tianjin, China
| |
Collapse
|
34
|
Fujisawa N, Oya S, Yoshida S, Tsuchiya T, Nakamura T, Indo M, Matsui T. A Prospective Randomized Study on the Preventive Effect of Japanese Herbal Kampo Medicine Goreisan for Recurrence of Chronic Subdural Hematoma. Neurol Med Chir (Tokyo) 2020; 61:12-20. [PMID: 33208583 PMCID: PMC7812313 DOI: 10.2176/nmc.oa.2020-0287] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Although the recurrence of chronic subdural hematoma (CSDH) after surgical treatment significantly affects the patients' quality of life, the recurrence rate has not improved in decades. Goreisan, a Japanese herbal Kampo medicine, promotes the hydragogue effect and has been empirically used in the treatment of CSDH in Japan. We conducted a prospective randomized study to investigate whether Goreisan treatment decreases the recurrence rate of CSDH. Between March 2013 and December 2018, a total of 224 patients who underwent initial burr hole surgery for CSDH were randomly assigned to receive Goreisan for 3 months (Group G) or no medication (Group N). The primary endpoint was symptomatic recurrence within 3 months postoperatively, and the secondary endpoint was complications, including the adverse effects of Goreisan. Of 224 randomized patients, 208 were included in the final analysis (104 in Group G and 104 in Group N). The overall recurrence rate was 9.1% (19/208). The recurrence rate of Group G was lower than that of Group N (5.8% vs 12.5%, P = 0.09), but the difference was not statistically significant. However, a significant preventive effect of Goreisan was found in 145 patients with high-risk computed tomography (CT) features, namely, homogeneous and separated types (5.6% vs 17.6%, P = 0.04). Although the present study did not prove the beneficial effect of Goreisan treatment, it suggested the importance of selecting patients with an increased risk of recurrence. A subset of patients whose hematoma showed homogeneous and separated patterns on CT image might benefit from Goreisan treatment.
Collapse
Affiliation(s)
- Naoaki Fujisawa
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University
| | - Soichi Oya
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University
| | - Shinsuke Yoshida
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University
| | - Tsukasa Tsuchiya
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University
| | - Takumi Nakamura
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University
| | - Masahiro Indo
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University
| | - Toru Matsui
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University
| |
Collapse
|
35
|
Wan KR, Qiu L, Saffari SE, Khong WXL, Ong JCL, See AA, Ng WH, King NKK. An open label randomized trial to assess the efficacy of tranexamic acid in reducing post-operative recurrence of chronic subdural haemorrhage. J Clin Neurosci 2020; 82:147-154. [PMID: 33317724 DOI: 10.1016/j.jocn.2020.10.053] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 10/09/2020] [Accepted: 10/21/2020] [Indexed: 01/26/2023]
Abstract
Chronic subdural haemorrhage (CSDH) is a common neurosurgical entity with complex pathophysiological pathways. The generally favourable surgical outcome may be affected by its associated risks including recurrence rates. We performed a prospective randomized multi-center clinical trial comparing the addition of tranexamic acid (TXA) to standard neurosurgical procedures for patients with symptomatic CSDH. The primary endpoint was CSDH requiring repeat surgery within 6-month post-operatively. Secondary endpoints were comparison of post-operative volumes between the treatment arms and safety evaluation of the dosing regime. 90 patients were analyzed with 49 patients in the observation arm and 41 patients in the TXA arm. The observation arm had five (10.2%) recurrences compared to two (4.8%, p = 0.221) in the TXA arm. Patients in the TXA arm demonstrated a greater reduction of their CSDH volume at 6 weeks follow up (36.6%) compared to the observation arm (23.3%, p = 0.6648). There were no reportable serious adverse events recorded in the observation arm, compared to 4 (9.8%) patients in the TXA arm. The addition of TXA treatment to standard surgical drainage of CSH did not significantly reduce symptomatic post-operative recurrence. Patients in the TXA arm had a delay in the CSDH recurrence with a comparative reduction of residual hematoma volume at the 6-week follow up although the effect was unsustained. Larger randomized trials with dose adjustments should be considered to investigate subgroups of patients that may benefit from this medical adjunct.
Collapse
Affiliation(s)
- Kai Rui Wan
- Department of Neurosurgery, National Neuroscience Institute, Singapore; Department of Neurosurgery, Singapore General Hospital, Singapore.
| | - Liming Qiu
- Department of Neurosurgery, National Neuroscience Institute, Singapore; Department of Neurosurgery, Singapore General Hospital, Singapore.
| | | | | | | | - Angela Anqi See
- Department of Neurosurgery, National Neuroscience Institute, Singapore; Department of Neurosurgery, Singapore General Hospital, Singapore
| | - Wai Hoe Ng
- Department of Neurosurgery, National Neuroscience Institute, Singapore; Department of Neurosurgery, Singapore General Hospital, Singapore.
| | - Nicolas Kon Kam King
- Department of Neurosurgery, National Neuroscience Institute, Singapore; Department of Neurosurgery, Singapore General Hospital, Singapore
| |
Collapse
|
36
|
Arham A, Zaragita N. Middle Meningeal Artery Embolization Following Burr Hole in Chronic Subdural Hematoma. Asian J Neurosurg 2020; 15:382-384. [PMID: 32656136 PMCID: PMC7335141 DOI: 10.4103/ajns.ajns_15_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 02/08/2020] [Accepted: 03/11/2020] [Indexed: 11/17/2022] Open
Abstract
Chronic subdural hematoma (CSDH) is a condition in which blood accumulates within the subdural space and may cause neurologic deficits. CSDH patients with neurologic deficits usually will undergo surgery, but reoccurrence is common. Middle meningeal artery (MMA) embolization has been proposed as one of the CSDH treatment options, either being used as a single treatment for the neurologically stable patients or certain conditions that may not allow patients to undergo surgery, or as a perioperative treatment. The authors reported a CSDH case with neurologic deficits who was on antiplatelet treatment that underwent both burr hole and MMA embolization for curation and prevention of rebleeding. The result showed near-complete blood resorption and no neurologic deficits.
Collapse
Affiliation(s)
- Abrar Arham
- Department of Neurosurgery, National Brain Center, Jakarta, Indonesia
| | - Nadya Zaragita
- Department of Neurosurgery, National Brain Center, Jakarta, Indonesia
| |
Collapse
|
37
|
Martinez-Perez R, Rayo N, Tsimpas A. Endovascular embolisation of the middle meningeal artery to treat chronic subdural haematomas: Effectiveness, safety, and the current controversy. A systematic review. Neurologia 2020; 38:S0213-4853(20)30133-X. [PMID: 32651091 DOI: 10.1016/j.nrl.2020.04.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 03/24/2020] [Accepted: 04/12/2020] [Indexed: 01/30/2023] Open
Abstract
INTRODUCTION Chronic subdural haematoma (CSDH) represents a clinical challenge due to its high recurrence rate. Endovascular middle meningeal artery embolisation (eMMAE) has emerged as an alternative for those patients presenting health problems or multiple recurrences of CSDH. Despite several encouraging reports, the safety profile, indications, and limitations of the technique are not clearly established. DEVELOPMENT This study aimed to evaluate the current evidence on eMMAE in patients with CSDH. We performed a systematic review of the literature, following the PRISMA guidelines. Our search yielded a total of 6 studies, in which a total of 164 patients with CSDH underwent eMMAE. The recurrence rate across all studies was 6.7%, and complications occurred in up to 6% of patients. CONCLUSIONS eMMAE is a feasible technique for treating CSDH, with a relatively low recurrence rate and an acceptable rate of complications. Further prospective and randomised studies are needed to formally establish a clear profile of the safety and effectiveness of the technique.
Collapse
Affiliation(s)
- R Martinez-Perez
- Department of Neurological Surgery, Wexner Medical Center, The Ohio State University, Columbus, Ohio, EE. UU..
| | - N Rayo
- Department of Biology, Western University, London, Ontario, Canadá
| | - A Tsimpas
- Division of Neurosurgery, Department of Surgery, Advocate Illinois Masonic Medical Center, Chicago, Illinois, EE. UU
| |
Collapse
|
38
|
Efficacy and safety of middle meningeal artery embolization in the management of refractory or chronic subdural hematomas: a systematic review and meta-analysis. Acta Neurochir (Wien) 2020; 162:499-507. [PMID: 31900658 DOI: 10.1007/s00701-019-04161-3] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 11/30/2019] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Refractory or chronic subdural hematomas (cSDH) constitute a challenging entity that neurosurgeons face frequently nowadays. Middle meningeal artery embolization (MMAE) has emerged in the recent years as a promising treatment option. However, solid evidence that can dictate management guidelines is still lacking. METHODS We conducted a systematic review and meta-analysis (MA) in compliance with the PRISMA guidelines to evaluate the efficacy and safety of MMAE compared with conventional treatments for refractory or cSDH. Databases were searched up to March 2019. Using a random-effects model, meta-analyses of proportions and risk difference were conducted recurrence, need for surgical rescue, and complications. RESULTS Eleven studies (177 patients) were included. Majority (116, 69%) were males with a weighted mean age of 71 + -19.5 years. Meta-analysis of proportions showed treatment failure to be 2.8%, need for surgical rescue 2.7%, and embolization-related complications 1.2%. Meta-analysis of risk-difference between embolized and non-embolized patients showed a 26% (p < 0.001, 95% CI 21%-31%, I2 = 0) lower risk of hematoma recurrence in MMAE. Similarly, in the embolized group, the need for surgical rescue was 20% less (p < 0.001, 95% CI = 12%-27%, I2 = 12.4), and complications were 3.6% less (p = 0.008, 95% CI 1%-6%, I2 = 0) compared to conventional groups. CONCLUSIONS Although MMAE appears to be a promising treatment for refractory or cSDH, drawing definitive conclusions remains limited by paucity of data and small sample sizes. Multicenter, randomized, prospective trials are needed to compare embolization to conventional treatments like watchful waiting, medical management, or surgical evacuation. More extensive research on MMAE could begin a new era in the minimally invasive management of cSDH.
Collapse
|
39
|
Xu M, Wang WH, Zhu SQ, Tan WG, Jin XG, Lu W, Chen L. Effects of minimally invasive approaches on chronic subdural hematoma by novel YL-1 puncture needle and burr-hole methods. Acta Neurol Belg 2020; 120:37-42. [PMID: 29623601 DOI: 10.1007/s13760-018-0914-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 03/19/2018] [Indexed: 11/28/2022]
Abstract
The objective of this study is to investigate effects of minimally invasive approaches on outcome of chronic subdural hematoma (CSDH) by novel YL-1 puncture needle and burr-hole methods. A retrospective analysis was performed in 158 hospitalized CSDH patients from January, 2013 to December, 2017 in Kunshan Hospital of Traditional Chinese Medicine. Patients' gender, age, history of trauma, volume of hematoma, hematoma location, application of urokinase, surgical approach, the operation time, hospitalized time, and CT scans 3 months after discharge were recorded. Prognostic indicators including symptom relief and post-hospital neuro-imaging findings were extracted to evaluate surgical efficacy. Statistical methods were conducted to evaluate surgical efficacy. Both YL-1 puncture needle and burr-hole surgeries had a satisfying follow-up (93.67%). There was non-significant group difference in follow-up results (p > 0.05). While YL-1 needle group needs less operation time ((p < 0.001) and hospitalized time (p < 0.001), gender (p = 0.144), age (p = 0.394), history of head trauma (p = 0.445), volume of hematoma (p = 0.068), hematoma location (p = 0.281), and application of urokinase (p = 0.545) were shown non-significantly associated with these two minimally invasive approaches. Volume of hematoma was significantly associated with follow-up outcomes (p = 0.016). Novel YL-1 puncture needle and classic burr-hole craniotomy are both proved to be safe and effective minimally invasive surgeries, which can provide an early intervention and minimally invasive strategy for neurosurgeons.
Collapse
Affiliation(s)
- Min Xu
- Department of Neurosurgery, Kunshan Hospital of Traditional Chinese Medicine, Kunshan Affiliated Hospital of Nanjing University of Chinese Medicine, Kunshan, 215300, Jiangsu, China
| | - Wen-Hua Wang
- Department of Neurosurgery, Kunshan Hospital of Traditional Chinese Medicine, Kunshan Affiliated Hospital of Nanjing University of Chinese Medicine, Kunshan, 215300, Jiangsu, China
| | - Sheng-Qiang Zhu
- Department of Neurosurgery, Kunshan Hospital of Traditional Chinese Medicine, Kunshan Affiliated Hospital of Nanjing University of Chinese Medicine, Kunshan, 215300, Jiangsu, China
| | - Wei-Guo Tan
- Department of Neurosurgery, Kunshan Hospital of Traditional Chinese Medicine, Kunshan Affiliated Hospital of Nanjing University of Chinese Medicine, Kunshan, 215300, Jiangsu, China
| | - Xue-Gang Jin
- Department of Neurosurgery, Kunshan Hospital of Traditional Chinese Medicine, Kunshan Affiliated Hospital of Nanjing University of Chinese Medicine, Kunshan, 215300, Jiangsu, China
| | - Wei Lu
- Department of Neurosurgery, Kunshan Hospital of Traditional Chinese Medicine, Kunshan Affiliated Hospital of Nanjing University of Chinese Medicine, Kunshan, 215300, Jiangsu, China
| | - Long Chen
- Department of Neurosurgery, Kunshan Hospital of Traditional Chinese Medicine, Kunshan Affiliated Hospital of Nanjing University of Chinese Medicine, Kunshan, 215300, Jiangsu, China.
| |
Collapse
|
40
|
Huang CT, Sun JM, Hsieh CT, Chen YH, Chang JY, Wong CS. Association between nonsteroidal anti-inflammatory drugs and lower incidence of surgical treatment of chronic subdural hematoma: A population-based study. FORMOSAN JOURNAL OF SURGERY 2020. [DOI: 10.4103/fjs.fjs_23_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
41
|
Jiang R, Zhao S, Wang R, Feng H, Zhang J, Li X, Mao Y, Yuan X, Fei Z, Zhao Y, Yu X, Poon WS, Zhu X, Liu N, Kang D, Sun T, Jiao B, Liu X, Yu R, Zhang J, Gao G, Hao J, Su N, Yin G, Zhu X, Lu Y, Wei J, Hu J, Hu R, Li J, Wang D, Wei H, Tian Y, Lei P, Dong JF, Zhang J. Safety and Efficacy of Atorvastatin for Chronic Subdural Hematoma in Chinese Patients: A Randomized ClinicalTrial. JAMA Neurol 2019; 75:1338-1346. [PMID: 30073290 DOI: 10.1001/jamaneurol.2018.2030] [Citation(s) in RCA: 153] [Impact Index Per Article: 30.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Chronic subdural hematoma (CSDH) is a trauma-associated condition commonly found in elderly patients. Surgery is currently the treatment of choice, but it carries a significant risk of recurrence and death. Nonsurgical treatments remain limited and ineffective. Our recent studies suggest that atorvastatin reduces hematomas and improves the clinical outcomes of patients with CSDH. Objective To investigate the safety and therapeutic efficacy of atorvastatin to nonsurgically treat patients with CSDH. Design, Setting, and Participants The Effect of Atorvastatin on Chronic Subdural Hematoma (ATOCH) randomized, placebo-controlled, double-blind phase II clinical trial was conducted in multiple centers in China from February 2014 to November 2015. For this trial, we approached 254 patients with CSDH who received a diagnosis via a computed tomography scan; of these, 200 (78.7%) were enrolled because 23 patients (9.1%) refused to participate and 31 (12.2%) were disqualified. Interventions Patients were randomly assigned to receive either 20 mg of atorvastatin or placebo daily for 8 weeks and were followed up for an additional 16 weeks. Main Outcomes and Measures The primary outcome was change in hematoma volume (HV) by computed tomography after 8 weeks of treatment. The secondary outcomes included HV measured at the 4th, 12th, and 24th weeks and neurological function that was evaluated using the Markwalder grading scale/Glasgow Coma Scale and the Barthel Index at the 8th week. Results One hundred ninety-six patients received treatment (169 men [86.2%]; median [SD] age, 63.6 [14.2] years). The baseline HV and clinical presentations were similar between patients who were taking atorvastatin (98 [50%]) and the placebo (98 [50%]). After 8 weeks, the HV reduction in patients who were taking atorvastatin was 12.55 mL more than those taking the placebo (95% CI, 0.9-23.9 mL; P = .003). Forty-five patients (45.9%) who were taking atorvastatin significantly improved their neurological function, but only 28 (28.6%) who were taking the placebo did, resulting in an adjusted odds ratio of 1.957 for clinical improvements (95% CI, 1.07-3.58; P = .03). Eleven patients (11.2%) who were taking atorvastatin and 23 (23.5%) who were taking the placebo underwent surgery during the trial for an enlarging hematoma and/or a deteriorating clinical condition (hazard ratio, 0.47; 95% CI, 0.24-0.92; P = .03). No significant adverse events were reported. Conclusions and Relevance Atorvastatin may be a safe and efficacious nonsurgical alternative for treating patients with CSDH. Trial Registration ClinicalTrials.gov Identifier: NCT02024373.
Collapse
Affiliation(s)
- Rongcai Jiang
- Key Laboratory of Post-Neurotrauma Neurorepair and Regeneration in Central Nervous System, Ministry of Education in China and Tianjin, Tianjin Neurological Institute, Tianjin, China
| | - Shiguang Zhao
- Department of Neurosurgery, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Renzhi Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Beijing, China
| | - Hua Feng
- Department of Neurosurgery, Southwest Hospital, Chongqing, China
| | - Jianmin Zhang
- Department of Neurosurgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xingang Li
- Department of Neurosurgery, Qilu Hospital of Shandong University, Jinan, China
| | - Ying Mao
- Department of Neurosurgery, Huashan Hospital Fudan University, Shanghai, China
| | - Xianrui Yuan
- Department of Neurosurgery, Xiangya Hospital of Central South University, Changsha, China
| | - Zhou Fei
- Department of Neurosurgery, Xijing Hospital, Xian, China
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing TianTan Hospital, the Capital Medical University, Beijing, China
| | - Xinguang Yu
- Department of Neurosurgery, General Hospital of Chinese People's Liberation Army, Beijing, China
| | - Wai Sang Poon
- Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Shatin, Hong Kong
| | - Xide Zhu
- Department of Neurosurgery, Linyi People's Hospital, Linyi, China
| | - Ning Liu
- Department of Neurosurgery, Jiangsu Provincial Hospital, Nanjing Medical University First Affiliated Hospital, Nanjing, China
| | - Dezhi Kang
- Department of Neurosurgery, First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Tao Sun
- Department of Neurosurgery, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Baohua Jiao
- Department of Neurosurgery, Second Affiliated Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xianzhi Liu
- Department of Neurosurgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Rutong Yu
- Department of Neurosurgery, Affiliated Hospital of Xuzhou Medical College, Xuzhou, China
| | - Junyi Zhang
- Department of Neurosurgery, Central Hospital of Erdos, Erdos, China
| | - Guodong Gao
- Department of Neurosurgery, Xi'an Tangdu Hospital of the fourth Military Medical University, Xian, China
| | - Jiehe Hao
- Department of Neurosurgery, First Affiliated Hospital of Shanxi Medical University, Taiyuan, China
| | - Ning Su
- Department of Neurosurgery, Provincial People's Hospital of Inner Mongolia, Huhehot, China
| | - Gangfeng Yin
- Department of Neurosurgery, Cangzhou Central Hospital, Cangzhou, China
| | - Xingen Zhu
- Department of Neurosurgery, Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yicheng Lu
- Department of Neurosurgery, Shanghai Changzheng Hospital, Shanghai, China
| | - Junji Wei
- Department of Neurosurgery, Peking Union Medical College Hospital, Beijing, China
| | - Jin Hu
- Department of Neurosurgery, Huashan Hospital Fudan University, Shanghai, China
| | - Rong Hu
- Department of Neurosurgery, Southwest Hospital, Chongqing, China
| | - Jianrong Li
- Department of Neurosurgery, 117th Hospital of Chinese People's Liberation Army, Hangzhou, China
| | - Dong Wang
- Key Laboratory of Post-Neurotrauma Neurorepair and Regeneration in Central Nervous System, Ministry of Education in China and Tianjin, Tianjin Neurological Institute, Tianjin, China
| | - Huijie Wei
- Key Laboratory of Post-Neurotrauma Neurorepair and Regeneration in Central Nervous System, Ministry of Education in China and Tianjin, Tianjin Neurological Institute, Tianjin, China
| | - Ye Tian
- Key Laboratory of Post-Neurotrauma Neurorepair and Regeneration in Central Nervous System, Ministry of Education in China and Tianjin, Tianjin Neurological Institute, Tianjin, China
| | - Ping Lei
- Laboratory of Neuro-Trauma and Neurodegenerative Disorders, Tianjin Geriatrics Institute, Tianjin Medical University General Hospital, Tianjin, China.,Department of Geriatrics, Tianjin Medical University General Hospital, Tianjin, China
| | - Jing-Fei Dong
- Bloodworks Research Institute, Division of Hematology, Department of Medicine, University of Washington School of Medicine, Seattle
| | - Jianning Zhang
- Key Laboratory of Post-Neurotrauma Neurorepair and Regeneration in Central Nervous System, Ministry of Education in China and Tianjin, Tianjin Neurological Institute, Tianjin, China
| |
Collapse
|
42
|
Court J, Touchette CJ, Iorio-Morin C, Westwick HJ, Belzile F, Effendi K. Embolization of the Middle meningeal artery in chronic subdural hematoma - A systematic review. Clin Neurol Neurosurg 2019; 186:105464. [PMID: 31600604 DOI: 10.1016/j.clineuro.2019.105464] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 07/09/2019] [Accepted: 08/06/2019] [Indexed: 12/15/2022]
Abstract
Chronic subdural hematomas (cSDH) are one of the most frequent reasons for consultation in neurosurgery. Multiple authors have proposed middle meningeal artery embolization (MMAE) as an option in cSDH patients to manage recurrence or avoid surgery altogether. Although many articles have been published on the matter, the current body of evidence still has to be evaluated before MMAE is integrated into clinical practice. The goal of this study was to review the evidence on MMAE in cSDH to assess its safety, feasibility, indications and efficacy. We performed a systematic review of the literature according to PRISMA guidelines using multiple electronic databases. Our search yielded a total of 18 original articles from which data were extracted. A total of 190 patients underwent MMAE from which 81.3% were symptomatic cSDH. Over half (52.3%) of the described population were undergoing antithrombotic therapy. Most (83%) procedures used polyvinyl alcohol (PVA) particles and no complications were reported regarding the embolization procedures. Although the definition of resolution varied among authors, cSDH resolution was reported in 96.8% of cases. MMAE is a feasible technique for cSDH, but the current body of evidence does not yet support its use as a standard treatment. Further studies with a higher level of evidence are necessary before MMAE can be formally recommended.
Collapse
Affiliation(s)
- Jordan Court
- Department of radiology, Université de Sherbrooke, Québec, Canada.
| | - Charles J Touchette
- Division of neurosurgery, Department of surgery, Université de Sherbrooke, Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Christian Iorio-Morin
- Division of neurosurgery, Department of surgery, Université de Sherbrooke, Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Harrison J Westwick
- Division of neurosurgery, Department of surgery, Université de Montreal, Centre hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - François Belzile
- Department of radiology, Université de Sherbrooke, Québec, Canada
| | - Khaled Effendi
- Division of neurosurgery, Department of surgery, Université de Sherbrooke, Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| |
Collapse
|
43
|
Zheng F, Qiu C, Zou L, Yang S, Krischek B. Letter: Middle Meningeal Artery Embolization for Chronic Subdural Hematoma: A Series of 60 Cases. Neurosurgery 2019; 85:E392. [DOI: 10.1093/neuros/nyz136] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
44
|
Zhang H, Wu J, Zhang Z, Qian H, Wang Y, Yang M, Cheng Y, Tang S. Association of atorvastatin with the risk of hepatotoxicity: a pilot prescription sequence symmetry analysis. Ther Clin Risk Manag 2019; 15:803-810. [PMID: 31417267 PMCID: PMC6602299 DOI: 10.2147/tcrm.s204860] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 05/27/2019] [Indexed: 01/01/2023] Open
Abstract
Purpose This study aimed to evaluate Atorvastatin (ATO)-associated hepatotoxicity using prescription sequence symmetry analysis (PSSA), based on a health insurance database of a Chinese population living in Jiangsu Province, China. Methods Patients prescribed ATO and hepatoprotective drugs in 2017 were identified, and the run-in period was determined based on the "waiting-time" distribution. Adjusted sequence ratio (ASR) and 95% confidence interval (95% CI) were calculated to estimate the risk of ATO-associated hepatotoxicity under different time intervals or based on gender and age stratification. Results A total of 2,549 patients, with 1,518 filling the ATO prescription first and 1,031 filling the ATO prescription second, were analyzed. After setting the run-in period as 30 days and the time interval as 15, 30, 60, 90, 120, and 180 days, the ASRs were 1.492 (95% CI: 1.367-1.652), 1.399 (95% CI: 1.308-1.508), 1.280 (95% CI: 1.213-1.357), 1.292 (95% CI: 1.234-1.356), 1.278 (95% CI: 1.226-1.336), and 1.274 (95% CI: 1.229-1.323), respectively. No significant difference was observed between different genders and ages (χ2=0.161, P=0.688; χ2=1.565, P=0.211, respectively). Conclusion This is the first study conducted in a real-world setting to evaluate the relationship between ATO and hepatotoxicity using the PSSA in a Chinese population. We found a 1.3- to 1.5-fold increase in risk of hepatotoxicity following ATO, with the greater risk occurring within the first 30 days of treatment.
Collapse
Affiliation(s)
- Haiping Zhang
- Department of Epidemiology, School of Public Health, Nanjing Medical University, Nanjing 211166, Jiangsu, People's Republic of China
| | - Jiani Wu
- Department of Epidemiology, School of Public Health, Nanjing Medical University, Nanjing 211166, Jiangsu, People's Republic of China
| | - Zhuolin Zhang
- Department of Clinical Pharmacy, School of Pharmacy, Nanjing Medical University, Nanjing 211166, Jiangsu, People's Republic of China
| | - Haisheng Qian
- Department of Internal Medicine, The First Clinical Medical College, Nanjing Medical University, Nanjing, Jiangsu 210029, People's Republic of China
| | - Yifan Wang
- Department of Epidemiology, School of Public Health, Nanjing Medical University, Nanjing 211166, Jiangsu, People's Republic of China
| | - Miaomiao Yang
- Department of Epidemiology, School of Public Health, Nanjing Medical University, Nanjing 211166, Jiangsu, People's Republic of China
| | - Yinchu Cheng
- Department of Pharmacy, Peking University Third Hospital, Beijing 100191, People's Republic of China
| | - Shaowen Tang
- Department of Epidemiology, School of Public Health, Nanjing Medical University, Nanjing 211166, Jiangsu, People's Republic of China
| |
Collapse
|
45
|
An Exhaustive Drainage Strategy in Burr-hole Craniostomy for Chronic Subdural Hematoma. World Neurosurg 2019; 126:e1412-e1420. [DOI: 10.1016/j.wneu.2019.03.111] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 03/10/2019] [Accepted: 03/11/2019] [Indexed: 12/14/2022]
|
46
|
Nakagawa I, Park HS, Kotsugi M, Wada T, Takeshima Y, Matsuda R, Nishimura F, Yamada S, Motoyama Y, Park YS, Kichikawa K, Nakase H. Enhanced Hematoma Membrane on DynaCT Images During Middle Meningeal Artery Embolization for Persistently Recurrent Chronic Subdural Hematoma. World Neurosurg 2019; 126:e473-e479. [DOI: 10.1016/j.wneu.2019.02.074] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 02/06/2019] [Accepted: 02/07/2019] [Indexed: 11/28/2022]
|
47
|
Fernandes de Oliveira M. Chronic Subdural Hematomas and Pursuit of Nonsurgical Treatment Alternatives. World Neurosurg 2019; 126:481-483. [PMID: 30922902 DOI: 10.1016/j.wneu.2019.03.151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Accepted: 03/04/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Matheus Fernandes de Oliveira
- Hospital do Servidor Público Estadual de São Paulo, São Paulo, Brazil; Hospital das Clínicas da Faculdade de Medicina da USP, São Paulo, Brazil; DFV Neuro, São Paulo, Brazil.
| |
Collapse
|
48
|
Srivatsan A, Mohanty A, Nascimento FA, Hafeez MU, Srinivasan VM, Thomas A, Chen SR, Johnson JN, Kan P. Middle Meningeal Artery Embolization for Chronic Subdural Hematoma: Meta-Analysis and Systematic Review. World Neurosurg 2019; 122:613-619. [DOI: 10.1016/j.wneu.2018.11.167] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 11/18/2018] [Indexed: 11/13/2022]
|
49
|
Tang R, Shi J, Li X, Zou Y, Wang L, Chen Y, Yan R, Gao B, Feng H. Effects of Atorvastatin on Surgical Treatments of Chronic Subdural Hematoma. World Neurosurg 2018; 117:e425-e429. [PMID: 29920396 DOI: 10.1016/j.wneu.2018.06.047] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 06/06/2018] [Accepted: 06/08/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To investigate the effects of atorvastatin on the surgical treatment of patients with chronic subdural hematoma (CSDH). METHODS Our retrospective study included 245 consecutive adult patients undergoing burr-hole craniotomy for CSDH. Data included baseline characteristics and recurrence, postoperative complications, and mortality. Univariate and multivariate regression models analyzed the association between administration of atorvastatin perioperatively and recurrence rates. RESULTS Multivariate analysis showed perioperative atorvastatin administration (odds ratio [OR] 0.336; P = 0.039), diabetes mellitus (OR 3.949, P = 0.010), and GCS of 15 preoperatively (OR 0.197; P = 0.020) to be significantly related to recurrence risk. Postoperative complications and mortality did not significantly differ between patients with and those without atorvastatin therapy. CONCLUSIONS Our findings demonstrate that the administration of atorvastatin perioperatively is associated with a lower risk of CSDH recurrence rate. The use of atorvastatin perioperatively was not associated with higher rates of morbidity or mortality.
Collapse
Affiliation(s)
- Rongrui Tang
- Department of Neurosurgery, Southwest Hospital, Army Medical University, Chongqing, China
| | - Jiantao Shi
- Department of Neurosurgery, Southwest Hospital, Army Medical University, Chongqing, China
| | - Xuegang Li
- Department of Neurosurgery, Southwest Hospital, Army Medical University, Chongqing, China
| | - Yongjie Zou
- Department of Neurosurgery, No. 184 of PLA Hospital, Yingtan, China
| | - Long Wang
- Department of Neurosurgery, Southwest Hospital, Army Medical University, Chongqing, China
| | - Yujie Chen
- Department of Neurosurgery, Southwest Hospital, Army Medical University, Chongqing, China
| | - Rubin Yan
- Department of Rehabilitation, Southwest Hospital, Army Medical University, Chongqing, China
| | - Boyuan Gao
- Department of Neurosurgery, Southwest Hospital, Army Medical University, Chongqing, China
| | - Hua Feng
- Department of Neurosurgery, Southwest Hospital, Army Medical University, Chongqing, China.
| |
Collapse
|
50
|
Holl DC, Volovici V, Dirven CMF, Peul WC, van Kooten F, Jellema K, van der Gaag NA, Miah IP, Kho KH, den Hertog HM, Lingsma HF, Dammers R. Pathophysiology and Nonsurgical Treatment of Chronic Subdural Hematoma: From Past to Present to Future. World Neurosurg 2018; 116:402-411.e2. [PMID: 29772364 DOI: 10.1016/j.wneu.2018.05.037] [Citation(s) in RCA: 108] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Accepted: 05/05/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND Chronic subdural hematoma (CSDH) is one of the more frequent pathologic entities in daily neurosurgical practice. Historically, CSDH was considered progressive recurrent bleeding with a traumatic cause. However, recent evidence has suggested a complex intertwined pathway of inflammation, angiogenesis, local coagulopathy, recurrent microbleeds, and exudates. The aim of the present review is to collect existing data on pathophysiology of CSDH to direct further research questions aiming to optimize treatment for the individual patient. METHODS We performed a thorough literature search in PubMed, Ovid, EMBASE, CINAHL, and Google scholar, focusing on any aspect of the pathophysiology and nonsurgical treatment of CSDH. RESULTS After a (minor) traumatic event, the dural border cell layer tears, which leads to the extravasation of cerebrospinal fluid and blood in the subdural space. A cascade of inflammation, impaired coagulation, fibrinolysis, and angiogenesis is set in motion. The most commonly used treatment is surgical drainage. However, because of the pathophysiologic mechanisms, the mortality and high morbidity associated with surgical drainage, drug therapy (dexamethasone, atorvastatin, tranexamic acid, or angiotensin-converting enzyme inhibitors) might be a beneficial alternative in many patients with CSDH. CONCLUSIONS Based on pathophysiologic mechanisms, animal experiments, and small patient studies, medical treatment may play a role in the treatment of CSDH. There is a lack of level I evidence in the nonsurgical treatment of CSDH. Therefore, randomized controlled trials, currently lacking, are needed to assess which treatment is most effective in each individual patient.
Collapse
Affiliation(s)
- Dana C Holl
- Department of Neurosurgery, Erasmus Medical Center, Erasmus MC Stroke Center, Rotterdam, The Netherlands.
| | - Victor Volovici
- Department of Neurosurgery, Erasmus Medical Center, Erasmus MC Stroke Center, Rotterdam, The Netherlands; Department of Public Health and Medical Decision Making, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Clemens M F Dirven
- Department of Neurosurgery, Erasmus Medical Center, Erasmus MC Stroke Center, Rotterdam, The Netherlands
| | - Wilco C Peul
- Department of Neurosurgery, Leiden University Medical Center, Leiden, Haaglanden MC and Haga Teaching Hospital, The Hague, The Netherlands
| | - Fop van Kooten
- Department of Neurology, Erasmus Medical Center, Erasmus MC Stroke Center, Rotterdam, The Netherlands
| | - Korné Jellema
- Department of Neurology, Haaglanden Medical Center, The Hague, The Netherlands
| | - Niels A van der Gaag
- Department of Neurosurgery, Leiden University Medical Center, Leiden, Haaglanden MC and Haga Teaching Hospital, The Hague, The Netherlands
| | - Ishita P Miah
- Department of Neurology, Haaglanden Medical Center, The Hague, The Netherlands
| | - Kuan H Kho
- Department of Neurosurgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | | | - Hester F Lingsma
- Department of Public Health and Medical Decision Making, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Ruben Dammers
- Department of Neurosurgery, Erasmus Medical Center, Erasmus MC Stroke Center, Rotterdam, The Netherlands
| | | |
Collapse
|