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Wu L, Guo X, Ou Y, Yu X, Zhu B, Li Y, Liu W. Seizure after chronic subdural hematoma evacuation: associated factors and effect on clinical outcome. Front Neurol 2023; 14:1190878. [PMID: 37228408 PMCID: PMC10203208 DOI: 10.3389/fneur.2023.1190878] [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: 03/21/2023] [Accepted: 04/25/2023] [Indexed: 05/27/2023] Open
Abstract
Objective Chronic subdural hematoma (CSDH) is a common disease in neurosurgery, which usually occurs in the elderly. Seizure is one of the postoperative complications in CSDH patients and can affect patient outcomes. There is currently no consensus on whether antiepileptic drugs should be prescribed prophylactically. The aim of this study was to evaluate independent risk factors for postoperative seizures and unfavorable outcomes in CSDH patients. Methods We reviewed 1,244 CSDH patients who had undergone burr-hole craniotomy in this study. Patient clinical data, CT scan results, recurrence and outcome data were collected. We divided the patients into two groups based on whether they had a postoperative seizure. Percentages and χ2 tests were applied for categorical variables. Standard deviations and two-sided unpaired t-tests were applied for continuous variables. Stepwise logistic regression analyses were performed to identify the independent factors of postoperative seizures and unfavorable outcomes. Results The incidence of seizures after CSDH surgery was 4.2% in this study. There was no significant difference in recurrence rate between seizure and non-seizure patients (p = 0.948), and the outcome of seizure patients was significantly poor (p < 0.001). There are more postoperative complications in seizure patients (p < 0.001). Logistic regression analysis showed that the independent risk factors for postoperative seizures included drinking history (p = 0.031), cardiac disease (p = 0.037), brain infarction (p = 0.001) and trabecular hematoma (p < 0.001). The use of urokinase is a protective factor for postoperative seizures (p = 0.028). Hypertension is an independent risk factor for unfavorable outcome in seizure patients (p = 0.038). Conclusion Seizures after CSDH surgery were associated with postoperative complications, higher mortality and poorer clinical outcomes at follow-up. We believe that alcohol consumption, cardiac disease, brain infarction and trabecular hematoma are independent risk factors for seizures. The use of urokinase is a protective factor against seizures. Patients with postoperative seizures need more stringent management of their blood pressure. A prospective randomized study is necessary to determine which subgroups of CSDH patients would benefit from antiepileptic drugs prophylaxis.
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Affiliation(s)
- Liang Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xufei Guo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yunwei Ou
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, Beihang University, Beijing, China
| | - Xiaofan Yu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Bingcheng Zhu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yunfei Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Weiming Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Neurological Center, People’s Hospital of Ningxia Hui Autonomous Region (The Third Clinical Medical College, Ningxia Medical University), Yinchuan, China
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Lin MS. Subdural Lesions Linking Additional Intracranial Spaces and Chronic Subdural Hematomas: A Narrative Review with Mutual Correlation and Possible Mechanisms behind High Recurrence. Diagnostics (Basel) 2023; 13:diagnostics13020235. [PMID: 36673045 PMCID: PMC9857428 DOI: 10.3390/diagnostics13020235] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 12/11/2022] [Accepted: 01/05/2023] [Indexed: 01/10/2023] Open
Abstract
The purpose of this study was two-fold. The first was to investigate the pathologic mechanisms underlying the formation of subdural fluid collection, an umbrella term referring to a condition commonly seen in the clinical setting. Accumulation of the cerebrospinal fluid (CSF) in the subdural space can be referred to in this disease category, disregarding the underlying source of the subdural fluid. However, in these two clinical situations, especially after trauma or brain surgery, fluid collection from the subarachnoid space (subdural hygroma) or from the ventricle to the subarachnoid space and infusion into the subdural space (external hydrocephalus), surgical management of critical patients may adopt the strategies of burr-hole, subduroperitoneal shunt, or ventriculoperitoneal shunt, which present distinctly different thoughts. Crucially, the former can be further transformed into chronic subdural hematoma (CSDH). The second significant theme was the pathogenesis of CSDH. Once the potential dural border cell (DBC) layer is separated such as if a wound is formed, the physiological mechanisms that seem to promote wound healing will resume in the subdural space as follows: coagulation, inflammation, fibroblast proliferation, neovascularization, and fibrinolysis. These aptly correspond to several key characteristics of CSDH formation such as the presence of both coagulation and fibrinolysis signals within the clot, neomembrane formation, angiogenesis, and recurrent bleeding, which contribute to CSDH failing to coagulate and absorb easily. Such a complexity of genesis and the possibility of arising from multiple pathological patterns provide a reasonable explanation for the high recurrence rate, even after surgery. Among the various complex and clinically challenging subdural lesions, namely, CSDH (confined to the subdural space alone), subdural hygroma (linked in two spaces), and external hydrocephalus (linked in three spaces), the ability to fully understand the different pathological mechanisms of each, differentiate them clinically, and devote more interventional strategies (including anti-inflammatory, anti-angiogenic, and anti-fibrinolysis) will be important themes in the future.
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Affiliation(s)
- Muh-Shi Lin
- Division of Neurosurgery, Department of Surgery, Kuang Tien General Hospital, Taichung 43303, Taiwan; ; Tel.: +886-4-2665-1900
- Department of Biotechnology and Animal Science, College of Bioresources, National Ilan University, Yilan 26047, Taiwan
- Department of Biotechnology, College of Medical and Health Care, Hung Kuang University, Taichung 43302, Taiwan
- Department of Health Business Administration, College of Medical and Health Care, Hung Kuang University, Taichung 43302, Taiwan
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Vychopen M, Güresir E, Wach J. Anti-Inflammatory Drug Therapy in Chronic Subdural Hematoma: A Systematic Review and Meta-Analysis of Prospective Randomized, Double-Blind and Placebo-Controlled Trials. Int J Mol Sci 2022; 23:ijms232416198. [PMID: 36555838 PMCID: PMC9784956 DOI: 10.3390/ijms232416198] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 12/12/2022] [Accepted: 12/16/2022] [Indexed: 12/23/2022] Open
Abstract
Althoughanti-inflammatory drug therapy has been identified as potentially beneficial for patients suffering from chronic subdural hematoma (cSDH), contemporary literature presents contradictory results. In this meta-analysis, we aimed to investigate the impact of anti-inflammatory drug therapy on mortality and outcome. We searched for eligible randomized, placebo-controlled prospective trials (RTCs) on PubMed, Embase and Medline until July 2022. From 97 initially identified articles, five RTCs met the criteria and were included in our meta-analysis. Our results illustrate significantly lower rates of recurrent cSDH (OR: 0.35; 95% CI: 0.21-0.58, p = 0.0001) in patients undergoing anti-inflammatory therapy. In the subgroup of patients undergoing primary conservative treatment, anti-inflammatory therapy was associated with lower rates of "switch to surgery" cases (OR: 0.30; 95% CI: 0.14-0.63, p = 0.002). Despite these findings, anti-inflammatory drugs seemed to be associated with higher mortality rates in patients undergoing surgery (OR: 1.76; 95% CI: 1.03-3.01, p = 0.04), although in the case of primary conservative treatment, no effect on mortality has been observed (OR: 2.45; 95% CI: 0.35-17.15, p = 0.37). Further multicentric prospective randomized trials are needed to evaluate anti-inflammatory drugs as potentially suitable therapy for asymptomatic patients with cSDH to avoid the necessity of surgical hematoma evacuation on what are predominantly elderly, vulnerable, patients.
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Vychopen M, Hamed M, Bahna M, Racz A, Ilic I, Salemdawod A, Schneider M, Lehmann F, Eichhorn L, Bode C, Jacobs AH, Behning C, Schuss P, Güresir E, Vatter H, Borger V. A Validation Study for SHE Score for Acute Subdural Hematoma in the Elderly. Brain Sci 2022; 12:981. [PMID: 35892422 PMCID: PMC9330492 DOI: 10.3390/brainsci12080981] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/10/2022] [Accepted: 07/18/2022] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVE The aim of this study was the verification of the Subdural Hematoma in the Elderly (SHE) score proposed by Alford et al. as a mortality predictor in patients older than 65 years with nontraumatic/minor trauma acute subdural hematoma (aSDH). Additionally, we evaluated further predictors associated with poor outcome. METHODS Patients were scored according to age (1 point is given if patients were older than 80 years), GCS by admission (1 point for GCS 5-12, 2 points for GCS 3-4), and SDH volume (1 point for volume 50 mL). The sum of points determines the SHE score. Multivariate logistic regression analysis was performed to identify additional independent risk factors associated with 30-day mortality. RESULTS We evaluated 131 patients with aSDH who were treated at our institution between 2008 and 2020. We observed the same 30-day mortality rates published by Alford et al.: SHE 0: 4.3% vs. 3.2%, p = 1.0; SHE 1: 12.2% vs. 13.1%, p = 1.0; SHE 2: 36.6% vs. 32.7%, p = 0.8; SHE 3: 97.1% vs. 95.7%, p = 1.0 and SHE 4: 100% vs. 100%, p = 1.0. Additionally, 18 patients who developed status epilepticus (SE) had a mortality of 100 percent regardless of the SHE score. The distribution of SE among the groups was: 1 for SHE 1, 6 for SHE 2, 9 for SHE 3, and 2 for SHE 4. The logistic regression showed the surgical evacuation to be the only significant risk factor for developing the seizure. All patients who developed SE underwent surgery (p = 0.0065). Furthermore, SHE 3 and 4 showed no difference regarding the outcome between surgical and conservative treatment. CONCLUSIONS SHE score is a reliable mortality predictor for minor trauma acute subdural hematoma in elderly patients. In addition, we identified status epilepticus as a strong life-expectancy-limiting factor in patients undergoing surgical evacuation.
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Affiliation(s)
- Martin Vychopen
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany; (M.H.); (M.B.); (I.I.); (A.S.); (M.S.); (P.S.); (E.G.); (H.V.); (V.B.)
| | - Motaz Hamed
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany; (M.H.); (M.B.); (I.I.); (A.S.); (M.S.); (P.S.); (E.G.); (H.V.); (V.B.)
| | - Majd Bahna
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany; (M.H.); (M.B.); (I.I.); (A.S.); (M.S.); (P.S.); (E.G.); (H.V.); (V.B.)
| | - Attila Racz
- Department of Epileptology, University Hospital Bonn, 53127 Bonn, Germany;
| | - Inja Ilic
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany; (M.H.); (M.B.); (I.I.); (A.S.); (M.S.); (P.S.); (E.G.); (H.V.); (V.B.)
| | - Abdallah Salemdawod
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany; (M.H.); (M.B.); (I.I.); (A.S.); (M.S.); (P.S.); (E.G.); (H.V.); (V.B.)
| | - Matthias Schneider
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany; (M.H.); (M.B.); (I.I.); (A.S.); (M.S.); (P.S.); (E.G.); (H.V.); (V.B.)
| | - Felix Lehmann
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, 53127 Bonn, Germany; (F.L.); (L.E.); (C.B.)
| | - Lars Eichhorn
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, 53127 Bonn, Germany; (F.L.); (L.E.); (C.B.)
| | - Christian Bode
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, 53127 Bonn, Germany; (F.L.); (L.E.); (C.B.)
| | - Andreas H. Jacobs
- Department of Geriatric Medicine and Neurology, Johanniter Hospital Bonn, 53113 Bonn, Germany;
| | - Charlotte Behning
- Department of Medical Biometry, Informatics and Epidemiology, University Hospital Bonn, 53127 Bonn, Germany;
| | - Patrick Schuss
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany; (M.H.); (M.B.); (I.I.); (A.S.); (M.S.); (P.S.); (E.G.); (H.V.); (V.B.)
| | - Erdem Güresir
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany; (M.H.); (M.B.); (I.I.); (A.S.); (M.S.); (P.S.); (E.G.); (H.V.); (V.B.)
| | - Hartmut Vatter
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany; (M.H.); (M.B.); (I.I.); (A.S.); (M.S.); (P.S.); (E.G.); (H.V.); (V.B.)
| | - Valeri Borger
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany; (M.H.); (M.B.); (I.I.); (A.S.); (M.S.); (P.S.); (E.G.); (H.V.); (V.B.)
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Blaauw J, den Hertog HM, van Zundert JM, van der Gaag NA, Jellema K, Dammers R, Kho KH, Groen RJM, Lingsma HF, van der Naalt J, Jacobs B. Transient neurological deficit in patients with chronic subdural hematoma: a retrospective cohort analysis. J Neurol 2022; 269:3180-3188. [PMID: 34999957 DOI: 10.1007/s00415-021-10925-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 11/29/2021] [Accepted: 11/30/2021] [Indexed: 10/19/2022]
Abstract
RATIONALE Symptoms of chronic subdural hematoma (CSDH) vary widely, including transient neurological deficit(s) (TND). The precise prevalence and the clinical aspects of TND are yet to be determined. Most TNDs are regarded and treated as symptomatic seizures, but the rationale for this decision is not always clear. METHODS Patients with temporary symptoms were selected from a retrospective cohort of CSDH patients. We analyzed the association of TND characteristics with patients being classified as having a symptomatic seizure and with functional outcome using logistic regression analysis. RESULTS Of the included 1307 CSDH patients, 113 (8.6%) had at least one episode of TND. Most common TNDs were aphasia/dysphasia, impaired awareness or clonic movements. Of these 113 patients, 50 (44%) were diagnosed with symptomatic seizure(s) by their treating physician. Impaired awareness, clonic movements and the presence of 'positive symptoms' showed the strongest association with the diagnosis symptomatic seizure (OR 36, 95% CI 7.8-163; OR 24, 95% CI 6.4-85; and OR 3.1, 95% CI 1.3-7.2). Aphasia/dysphasia lowered the chance of TND being classified as symptomatic seizure together with a longer TND duration (OR 0.2, 95% CI 0.1-0.6; and OR 0.91, 95% CI 0.84-0.99). Treatment with anti-epileptic drugs was related to unfavorable functional outcome (aOR 5.4, 95% CI 1.4-20.7). CONCLUSION TND was not a rare phenomenon in our cohort of CSDH patients. A TND episode of 5 min, aphasia/dysphasia and/or absence of 'positive' symptoms are suggestive of a different TND pathophysiology than symptomatic seizures. Our results further suggest that treatment of TND in CSDH deserves careful consideration as management choices might influence patient outcome.
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Affiliation(s)
- Jurre Blaauw
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands. .,Department of Public Health, Center for Medical Decision Sciences, Erasmus Medical Center, Rotterdam, The Netherlands.
| | | | - Josje M van Zundert
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Niels A van der Gaag
- University Neurosurgical Center Holland (UNCH), Haaglanden Medical Center & Haga Teaching Hospital, Leiden & The Hague, Leiden University Medical Center, Leiden & The Hague and Leiden, The Netherlands
| | - Korné Jellema
- Department of Neurology, Haaglanden Medical Centre, The Hague, The Netherlands
| | - Ruben Dammers
- Department of Neurosurgery, Erasmus MC Stroke Center, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Kuan H Kho
- Department of Neurosurgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Rob J M Groen
- Department of Neurosurgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Hester F Lingsma
- Department of Public Health, Center for Medical Decision Sciences, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Joukje van der Naalt
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Bram Jacobs
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Blaauw J, Meelis GA, Jacobs B, Gaag NA, Jellema K, Kho KH, Groen RJ, Naalt J, Lingsma HF, den Hertog HM. Presenting symptoms and functional outcome of chronic subdural hematoma patients. Acta Neurol Scand 2022; 145:38-46. [PMID: 34448196 DOI: 10.1111/ane.13518] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 07/23/2021] [Accepted: 08/04/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND Patients with chronic subdural hematoma (CSDH) can present with a variety of signs and symptoms. The relationship of these signs and symptoms with functional outcome is unknown. Knowledge of these associations might aid clinicians in the choice to initiate treatment and may allow them to better inform patients on expected outcomes. OBJECTIVE To investigate if presenting signs and symptoms influence functional outcome in patients with CSDH. METHODS We conducted a retrospective analysis of consecutive CSDH patients in three hospitals. Glasgow Outcome Scale Extended (GOS-E) scores were obtained from the first follow-up visit after treatment. An ordinal multivariable regression analysis was performed, to assess the relationship between the different signs and symptoms on the one hand and functional outcome on the other adjusted for potential confounders. RESULTS We included 1,307 patients, of whom 958 (73%) were male and mean age was 74 (SD ± 11) years. Cognitive complaints were associated with lower GOS-E scores at follow-up (aOR 0.7, 95% CI: 0.5 - 0.8) Headache and higher Glasgow Coma Scale (GCS) scores were associated with higher GOS-E scores. (aOR 1.9, 95% CI: 1.5-2.3 and aOR 1.3, 95% CI: 1.2-1.4). CONCLUSION Cognitive complaints are independently associated with worse functional outcome, whereas headache and higher GCS scores are associated with better outcome. The increased probability of unfavorable outcome in patients with CSDH who present with cognitive complaints favors a more prominent place of assessing cognitive status at diagnosis.
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Affiliation(s)
- Jurre Blaauw
- Department of Neurology University of GroningenUniversity Medical Center Groningen Groningen The Netherlands
- Center for Medical Decision Sciences Department of Public Health Erasmus Medical Center Rotterdam The Netherlands
| | | | - Bram Jacobs
- Department of Neurology University of GroningenUniversity Medical Center Groningen Groningen The Netherlands
| | - Niels A. Gaag
- University Neurosurgical Center Holland (UNCHLeiden University Medical CenterHaaglanden Medical Center & Haga teaching hospitalLeiden & The Hague The Hague The Netherlands
| | - Korné Jellema
- Department of Neurology Haaglanden Medical Centre The Hague The Netherlands
| | - Kuan H. Kho
- Department of Neurosurgery Medisch Spectrum Twente Enschede The Netherlands
| | - Rob J.M. Groen
- Department of Neurosurgery University Medical Center Groningen Groningen The Netherlands
| | - Joukje Naalt
- Department of Neurology University of GroningenUniversity Medical Center Groningen Groningen The Netherlands
| | - Hester F. Lingsma
- Center for Medical Decision Sciences Department of Public Health Erasmus Medical Center Rotterdam The Netherlands
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Zhu F, Wang H, Li W, Han S, Yuan J, Zhang C, Li Z, Fan G, Liu X, Nie M, Bie L. Factors correlated with the postoperative recurrence of chronic subdural hematoma: An umbrella study of systematic reviews and meta-analyses. EClinicalMedicine 2022; 43:101234. [PMID: 34988412 PMCID: PMC8703229 DOI: 10.1016/j.eclinm.2021.101234] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 11/08/2021] [Accepted: 11/24/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Chronic subdural hematoma (CSDH) is a common neurological disease, and the surgical evacuation of subdural collection remains the primary treatment approach for symptomatic patients. Postoperative recurrence is a serious complication, and several factors are correlated with postoperative recurrence. METHODS We searched Embase, Web of Science, PubMed, and Cochrane Library from their establishment to September 2020. Reports on randomized, prospective, retrospective, and overall observational studies on the management of surgical patients with CSDH were searched, and an independent reviewer performed research quality assessment. Factors that affect the postoperative recurrence of CSDH were extracted: social demographics, drugs (as the main or auxiliary treatment), surgical management, imaging, and other risk factors. We evaluated the recurrence rate of each risk factor. A random effect model was used to perform a meta-analysis, and each risk factor affecting the postoperative recurrence of CSDH was then evaluated and graded. FINDINGS In total, 402 studies were included in this analysis and 32 potential risk factors were evaluated. Among these, 21 were significantly associated with the postoperative recurrence of CSDH. Three risk factors (male, bilateral hematoma, and no drainage) had convincing evidence. The classification of evidence can help clinicians identify significant risk factors for the postoperative recurrence of CSDH. INTERPRETATION Only few associations were supported by high-quality evidence. Factors with high-quality evidence may be important for treating and preventing CSDH recurrence. Our results can be used as a basis for improving clinical treatment strategies and designing preventive methods. FUNDING No funding was received.
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Affiliation(s)
- Fulei Zhu
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Haifeng Wang
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Wenchen Li
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Shuai Han
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Jiangyuan Yuan
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Chunyun Zhang
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Zean Li
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Guangyan Fan
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Xuanhui Liu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Meng Nie
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Li Bie
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
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Zöllner JP, Schmitt FC, Rosenow F, Kohlhase K, Seiler A, Strzelczyk A, Stefan H. Seizures and epilepsy in patients with ischaemic stroke. Neurol Res Pract 2021; 3:63. [PMID: 34865660 PMCID: PMC8647498 DOI: 10.1186/s42466-021-00161-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 10/11/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND With the increased efficacy of stroke treatments, diagnosis and specific treatment needs of patients with post-stroke seizures (PSS) and post-stroke epilepsy have become increasingly important. PSS can complicate the diagnosis of a stroke and the treatment of stroke patients, and can worsen post-stroke morbidity. This narrative review considers current treatment guidelines, the specifics of antiseizure treatment in stroke patients as well as the state-of-the-art in clinical and imaging research of post-stroke epilepsy. Treatment of PSS needs to consider indications for antiseizure medication treatment as well as individual clinical and social factors. Furthermore, potential interactions between stroke and antiseizure treatments must be carefully considered. The relationship between acute recanalizing stroke therapy (intravenous thrombolysis and mechanical thrombectomy) and the emergence of PSS is currently the subject of an intensive discussion. In the subacute and chronic post-stroke phases, important specific interactions between necessary antiseizure and stroke treatments (anticoagulation, cardiac medication) need to be considered. Among all forms of prevention, primary prevention is currently the most intensively researched. This includes specifically the repurposing of drugs that were not originally developed for antiseizure properties, such as statins. PSS are presently the subject of extensive basic clinical research. Of specific interest are the role of post-stroke excitotoxicity and blood-brain barrier disruption for the emergence of PSS in the acute symptomatic as well as late (> 1 week after the stroke) periods. Current magnetic resonance imaging research focussing on glutamate excitotoxicity as well as diffusion-based estimation of blood-brain barrier integrity aim to elucidate the pathophysiology of seizures after stroke and the principles of epileptogenesis in structural epilepsy in general. These approaches may also reveal new imaging-based biomarkers for prediction of PSS and post-stroke epilepsy. CONCLUSION PSS require the performance of individual risk assessments, accounting for the potential effectiveness and side effects of antiseizure therapy. The use of intravenous thrombolysis and mechanical thrombectomy is not associated with an increased risk of PSS. Advances in stroke imaging may reveal biomarkers for PSS.
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Affiliation(s)
- Johann Philipp Zöllner
- Department of Neurology and Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany.
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany.
| | | | - Felix Rosenow
- Department of Neurology and Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Konstantin Kohlhase
- Department of Neurology and Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Alexander Seiler
- Department of Neurology and Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany
| | - Adam Strzelczyk
- Department of Neurology and Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Hermann Stefan
- Department of Neurology - Biomagnetism, University Hospital Erlangen, Erlangen, Germany
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Wasfie T, Fitzpatrick N, Niasan M, Hille JL, Yapchai R, Hella J, Barber K, Brimmier A, Shapiro B. Factors Favoring the Development of Chronic Subdural Hematoma After Traumatic Acute Subdural Hematoma in the Elderly. Am Surg 2021; 88:372-375. [PMID: 34794326 DOI: 10.1177/00031348211056279] [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: 11/15/2022]
Abstract
INTRODUCTION Traumatic acute subdural hematoma (TASDH) is by far the most common traumatic brain injury in elderly patients presented to the emergency department, and a number of those treated conservatively will develop chronic subdural hematoma (CSDH). The factors contributing to chronicity were not well studied in the elderly; therefore, we retrospectively analyzed our elderly patients with acute subdural hematomas to identify the risk factors which might contribute to the development of subsequent CSDH. METHODS A retrospective analysis of 254 patients with TASDH admitted between 2012 and 2016 to our level 2 trauma department in a community hospital was collected. Data include age, sex, comorbid conditions, CT findings, anticoagulant therapy, surgical interventions, disposition after discharge, and mortality. Data on those readmitted within the first 2 months with the diagnosis of CSDH were also studied (group A), and compared to those not readmitted (group B). Multiple logistic regression was used to determine the risk factors associated with readmission at P ≤ .05. Institutional review board approval was obtained for this study. RESULTS There were 254 patients who were admitted with TASDH, 144 male (56.7%) and 110 female (43.3%), with the mean age of 71.4 (SD ± 19.38) years. Only 37 patients (14.6%) went for surgery in their initial admission. A total of 14 patients (5.6%) were readmitted subsequently with the diagnosis of CSDH within two months of initial discharge (group A). Only four patients (28.5%) were on anticoagulant therapy and these patients went for emergency craniotomy for evacuation of hematoma. All 14 patients had a history of coronary artery disease and hypertension and only 5 (35.7%) were diabetic. Review of head CT on initial admission of those patients revealed 4 patients (28.5%) had multiple lesions and 4 (28.5%) had tentorial/falax bleeding and 4 (28.5%) had a shift. The initial size and thickness of the bleeding was 1.4-5 mm. The adjusted model identified diabetes, race, and initial disposition as significant risk factors (P < .05). CONCLUSION Risk associated with the transformation of TASDH to CSDH is difficult to assess in those group of elderly patients because of the small number; however, diabetes, race, and initial disposition to home pointed toward a risk for future development of CSDH and those patients should be followed clinically and radiographically over the next few months after discharge, particularly those on anticoagulant therapy.
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Affiliation(s)
- Tarik Wasfie
- Department of Surgery/Trauma Section, 3577Ascension Genesys Hospital, Grand Blanc, MI, USA
| | - Nicholas Fitzpatrick
- Department of Surgery/Trauma Section, 3577Ascension Genesys Hospital, Grand Blanc, MI, USA
| | - Mursal Niasan
- Department of Surgery/Trauma Section, 3577Ascension Genesys Hospital, Grand Blanc, MI, USA
| | - Jennifer L Hille
- Department of Surgery/Trauma Section, 3577Ascension Genesys Hospital, Grand Blanc, MI, USA
| | - Raquel Yapchai
- Department of Surgery/Trauma Section, 3577Ascension Genesys Hospital, Grand Blanc, MI, USA
| | - Jennifer Hella
- Department of Academic Research, 3577Ascension Genesys Hospital, Grand Blanc, MI, USA
| | - Kimberly Barber
- Department of Academic Research, 3577Ascension Genesys Hospital, Grand Blanc, MI, USA
| | - Alexis Brimmier
- School of Osteopathic Medicine, 12266Michigan State University, Lansing, MI, USA
| | - Brian Shapiro
- Department of Surgery/Trauma Section, 3577Ascension Genesys Hospital, Grand Blanc, MI, USA
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Kizawa R, Sato T, Umehara T, Komatsu T, Omoto S, Iguchi Y. [A case of epileptic seizure that required differentiation from hyper-acute ischemic stroke: usefulness of comparing DWI and FLAIR]. Rinsho Shinkeigaku 2021; 61:166-171. [PMID: 33627578 DOI: 10.5692/clinicalneurol.cn-001496] [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] [Indexed: 11/05/2022]
Abstract
A 60-year-old man developed aphasia and transient right upper limb paresis in the presence of chronic subdural hematoma and was transferred to our hospital at an early stage. Cranial MRI within an hour after onset showed diffusion-weighted image (DWI) hyperintensity in the left parietal, temporal, and insular cortex and the pulvinar, and decreased apparent diffusion coefficient (ADC) in the left parietal cortex and pulvinar, suggesting a differential diagnosis of hyper-acute ischemic stroke. However, the distribution and timing of the MRI abnormalities were considered to be atypical for hyper-acute ischemic stroke. The area with both DWI hyperintensity and decreased ADC included the cerebral cortex adjacent to the hematoma and the ipsilateral pulvinar, and fluid-attenuated inversion recovery (FLAIR) hyperintensity co-existed with DWI hyperintensity within only an hour from onset. Furthermore, FLAIR images showed infiltration of the hematoma content into the subarachnoid space, which might have triggered the attack. These findings collectively led us to diagnose an epileptic seizure. The present case suggests that the distribution and timing of MRI abnormalities are essential to differentiate epileptic seizures from hyper-acute ischemic stroke.
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Affiliation(s)
| | - Takeo Sato
- Department of Neurology, The Jikei University School of Medicine
| | - Tadashi Umehara
- Department of Neurology, The Jikei University School of Medicine
| | - Teppei Komatsu
- Department of Neurology, The Jikei University School of Medicine
| | - Shusaku Omoto
- Department of Neurology, The Jikei University School of Medicine
| | - Yasuyuki Iguchi
- Department of Neurology, The Jikei University School of Medicine
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11
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Won SY, Dubinski D, Freiman T, Seifert V, Gessler F, Strzelczyk A, Konczalla J. Acute-on-chronic subdural hematoma: a new entity for prophylactic anti-epileptic treatment? Eur J Trauma Emerg Surg 2020; 48:933-942. [PMID: 32986132 PMCID: PMC9001543 DOI: 10.1007/s00068-020-01508-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 09/18/2020] [Indexed: 11/16/2022]
Abstract
Purpose Acute-on-chronic subdural hematoma (acSDH) describes acute bleeding into a chronic subdural hematoma (SDH), after surgery or second trauma. Because seizures are a well-known complication of SDH, associated with substantial morbidity and mortality, we aimed to analyze the incidence of acute symptomatic seizures (ASz), including status epilepticus, and determine the functional outcomes in this specific cohort of patients. Methods A retrospective analysis was performed, including patients with acSDH who were admitted to our department between 2010 and 2019. The incidence and timely onset of ASz and status epilepticus were evaluated. Functional outcomes at discharge and at 3–6 month follow-up were analyzed based on the modified Rankin scale. Results Of 506 patients with chronic SDH, 29 patients (5.7%) were diagnosed with acSDH. The overall incidence of ASz and status epilepticus were 72.4% and 10.3%, respectively. Favorable outcomes were identified in 11 patients (52.4%) in the ASz group compared with 6 patients (75%) in the non-ASz group. The mortality rate was higher in the ASz group compared with that in the control group (29% vs 0%). At follow-up, favorable outcomes were similar to those observed at discharge (52.4% in the ASz group and 71.4% in the control group). The mortality rate was still higher in the ASz group, at 32% compared with 14% for the control group. Conclusion AcSDH has a high risk for ASz, including status epilepticus, and is associated with unfavorable outcomes and high mortality. Thus, prophylactic treatment with antiepileptic drugs should be considered among this specific cohort of patients.
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Affiliation(s)
- Sae-Yeon Won
- Department of Neurosurgery, University Hospital, Goethe University, Schleusenweg 2-16, 60528, Frankfurt, Germany.
| | - Daniel Dubinski
- Department of Neurosurgery, University Hospital, Goethe University, Schleusenweg 2-16, 60528, Frankfurt, Germany
| | - Thomas Freiman
- Department of Neurosurgery, University Hospital, Goethe University, Schleusenweg 2-16, 60528, Frankfurt, Germany.,Department of Neurosurgery, University Medicine of Rostock, Rostock, Germany
| | - Volker Seifert
- Department of Neurosurgery, University Hospital, Goethe University, Schleusenweg 2-16, 60528, Frankfurt, Germany
| | - Florian Gessler
- Department of Neurosurgery, University Hospital, Goethe University, Schleusenweg 2-16, 60528, Frankfurt, Germany.,Department of Neurosurgery, University Medicine of Rostock, Rostock, Germany
| | - Adam Strzelczyk
- Department of Neurology and Epilepsy Center Frankfurt Rhine-Main, University Hospital, Goethe-University, Frankfurt am Main, Germany
| | - Juergen Konczalla
- Department of Neurosurgery, University Hospital, Goethe University, Schleusenweg 2-16, 60528, Frankfurt, Germany
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Role of prophylactic antiepileptic drugs in chronic subdural hematoma-a systematic review and meta-analysis. Neurosurg Rev 2020; 44:2069-2077. [PMID: 32910368 DOI: 10.1007/s10143-020-01388-y] [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: 07/29/2020] [Revised: 08/30/2020] [Accepted: 09/03/2020] [Indexed: 10/23/2022]
Abstract
Chronic subdural hematoma is a common neurosurgical pathology, which is more commonly seen in the elderly age group. Few patients with chronic subdural hematoma (cSDH) can have seizures-either before or after surgical intervention. Reported incidence of seizures varies from 0.7-18.5% in patients with cSDH. Many factors which have been proposed to increase the risk of seizures in these patients include the presence of encapsulated membranes, occult cortical injury, mass effect, or an acute hemorrhage. The role of prophylactic antiepileptic drugs is not very clear in cSDH. We reviewed the currently available evidence for the use of prophylactic antiepileptic drugs (AEDs) in patients with cSDH. We included 13 studies in the systematic review and 6 studies compared the incidence of seizures in patients who received antiepileptic drugs with those who did not. Our review did not find any significant reduction in the incidence of seizures in patients with cSDH following administration of antiepileptic drugs.
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Won SY, Dubinski D, Eibach M, Gessler F, Herrmann E, Keil F, Seifert V, Konczalla J, Behmanesh B. External validation and modification of the Oslo grading system for prediction of postoperative recurrence of chronic subdural hematoma. Neurosurg Rev 2020; 44:961-970. [PMID: 32112162 DOI: 10.1007/s10143-020-01271-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 12/18/2019] [Accepted: 02/13/2020] [Indexed: 10/24/2022]
Abstract
Recently, Oslo grading system (OGS) for prediction of recurrence in chronic subdural hematoma (cSDH) was introduced. The aim of the study was to validate and if applicable to modify the grading system. Data of all patients admitted to the Goethe University Hospital between 2016 and 2018 with chronic subdural hematoma were prospectively entered into a database. Dataset of patients with uni- (n = 272) and bilateral cSDH (n = 177) were used for the validation of OGS via logistic regression analysis. Additional predictors were identified and integrated to build a modified OGS (mOGS). Internal validation of the modified OGS was performed using same dataset of patients. The OGS showed a significant good predictive value with correlating increase of recurrence rate depending on the level of score in unilateral cSDH (p = 0.002). Regarding bilateral cSDH, there was no significant predictive value found (p = 0.921). By performing uni- and multivariate analysis, additional predictors for recurrence in uni- and bilateral cSDH were identified and integrated into the score system. Accordingly, the mOGS for unilateral cSDH inherited 4 components: previous OGS with 3 components (OR1.6) and seizure (OR2.5) (0 point, 0% recurrence rate; 1-2 points, 17.4%; 3-4 points, 30.6%; ≥ 5 points, 80%). Regarding bilateral cSDH, the mOGS consisted of 4 components as well: hypodense/gradation subtypes (OR3.3), postoperative unilateral volume > 80 mL (OR7.4), postoperative unilateral air trapping > 80 mL (OR15.3), and seizure (OR5.5) (0 point, 3.6% recurrence rate; 1 point, 30.6%; 2 points, 53.5%; 3 points, 58.3%; ≥ 4 points, 100%). Furthermore, the mOGS was internally verified showing high significant predictive power for recurrent hematoma in uni- (p = 0.004) and bilateral cSDH (p < 0.001). External validation of OGS showed accurate risk stratification of recurrence in unilateral cSDH; however, the validation failed for bilateral cSDH. Thus, mOGS was developed to strengthen its clinical utility and applicability.
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Affiliation(s)
- Sae-Yeon Won
- Department of Neurosurgery, University Hospital, Goethe-University, Frankfurt am Main, Germany.
| | - Daniel Dubinski
- Department of Neurosurgery, University Hospital, Goethe-University, Frankfurt am Main, Germany
| | - Michael Eibach
- Department of Neurosurgery, University Hospital, Goethe-University, Frankfurt am Main, Germany
| | - Florian Gessler
- Department of Neurosurgery, University Hospital, Goethe-University, Frankfurt am Main, Germany
| | - Eva Herrmann
- Department of Medicine, Institute of Biostatistics and Mathematical Modelling, Frankfurt am Main, Germany
| | - Fee Keil
- Department of Neuroradiology, University Hospital, Goethe-University, Frankfurt am Main, Germany
| | - Volker Seifert
- Department of Neurosurgery, University Hospital, Goethe-University, Frankfurt am Main, Germany
| | - Juergen Konczalla
- Department of Neurosurgery, University Hospital, Goethe-University, Frankfurt am Main, Germany
| | - Bedjan Behmanesh
- Department of Neurosurgery, University Hospital, Goethe-University, Frankfurt am Main, Germany
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