Outcome of contemporary surgery for chronic subdural haematoma: evidence based review

Comparative clinical outcomes of irrigation techniques in burr-hole craniostomy for chronic subdural hemorrhage: a multicenter cohort study

BACKGROUND

Chronic Subdural Hemorrhage(cSDH) is often treated with surgical blood drainage, but concerns about recurrence and outcomes persist. Surgical techniques, including irrigation, vary. This study compares the outcomes of irrigation in cSDH surgery.

MATERIALS AND METHODS

From September 2020 to September 2022, 92 cSDH patients underwent surgery. Two different irrigation methods were used: extensive irrigation (IG) and non-irrigation (NIG). Method of irrigation was selected by each surgeon's preference. Parameters measured included volume of hematoma changes, midline shifting, complications, and basic demographics. Recurrence was defined as symptomatic or hematoma expansion more than double the volume before surgery. Factors predicting recurrence and irrigation method impact were analyzed.

RESULTS

Eleven patients were excluded because of bilateral or related to other disease. We analyzed 81 patients (44 NIG, 37 IG). Recurrence occurred in 6 IG cases (16.2%) and 1 NIG case (2.3%). Irrigation method significantly affected recurrence (P = 0.043). Age, gender, medication, medical history, and preoperative measurements had no major impact on recurrence. NIG had unexpected cases of intracerebral hemorrhage.

CONCLUSION

Extensive irrigation may increase recurrence in cSDH drainage. Non-irrigation drainage had fewer recurrences, but unexpected complications arose. Careful drainage in non-irrigated cases is crucial.

Burr-hole drainage with or without irrigation for chronic subdural haematoma (FINISH): a Finnish, nationwide, parallel-group, multicentre, randomised, controlled, non-inferiority trial

BACKGROUND

Chronic subdural haematoma is a common surgically treated intracranial emergency. Burr-hole drainage surgery, to evacuate chronic subdural haematoma, involves three elements: creation of a burr hole for access, irrigation of the subdural space, and insertion of a subdural drain. Although the subdural drain has been established as beneficial, the therapeutic effect of subdural irrigation has not been addressed.

METHODS

The FINISH trial was an investigator-initiated, pragmatic, multicentre, nationwide, randomised, controlled, parallel-group, non-inferiority trial in five neurosurgical units in Finland that enrolled adults aged 18 years or older with a chronic subdural haematoma requiring burr-hole drainage. Patients were randomly assigned (1:1) by computer-generated block randomisation with block sizes of four, six, or eight, stratified by site, to burr-hole drainage either with or without subdural irrigation. All patients and staff were masked to treatment assignment apart from the neurosurgeon and operating room staff. A burr hole was drilled at the site of maximum haematoma thickness in both groups, and the subdural space was either irrigated or not irrigated before inserting a subdural drain, which remained in place for 48 h. Reoperations, functional outcome, mortality, and adverse events were recorded for 6 months after surgery. The primary outcome was the reoperation rate within 6 months. The non-inferiority margin was set at 7·5%. Key secondary outcomes that were also required to conclude non-inferiority were the proportion of participants with unfavourable functional outcomes (ie, modified Rankin Scale score of 4-6, where 0 indicates no symptoms and 6 indicates death) and mortality rate at 6 months. The primary and key secondary analyses were done in both the intention-to-treat and per-protocol populations. The trial was registered with ClinicalTrials.gov (NCT04203550) and is completed.

FINDINGS

From Jan 1, 2020, to Aug 17, 2022, we assessed 1644 patients for eligibility and 589 (36%) patients were randomly assigned to a treatment group and treated (294 assigned to drainage with irrigation and 295 assigned to drainage without irrigation; 165 [28%] women and 424 [72%] men). The 6-month follow-up period extended until Feb 14, 2023. In the intention-to-treat analysis, 54 (18·3%) of 295 participants required reoperation in the group assigned to receive no irrigation versus 37 (12·6%) of 294 in the group assigned to receive irrigation (difference of 6·0 percentage points, 95% CI 0·2-11·7; p=0·30; adjusted for study site). There were no significant between-group differences in the proportion of people with modified Rankin Scale score of 4-6 (37 [13·1%] of 283 in the no-irrigation group vs 36 [12·6%] of 285 in the irrigation group; p=0·89) or mortality rate (18 [6·1%] of 295 in the no-irrigation group vs 21 [7·1%] of 294 in the irrigation group; p=0·58). The findings of the primary intention-to-treat analysis were not materially altered in the per-protocol analysis. There were no significant between-group differences in the number of adverse events, and the most frequent severe adverse events were systemic infections (26 [8·8%] of 295 participants who did not receive irrigation vs 22 [7·5%] of 294 participants who received irrigation), intracranial haemorrhage (13 [4·4%] vs seven [2·4%]), and epileptic seizures (five [1·7%] vs nine [3·1%]).

INTERPRETATION

We could not conclude non-inferiority of burr-hole drainage without irrigation. The reoperation rate was 6·0 percentage points higher after burr-hole drainage without subdural irrigation than with subdural irrigation. Considering that there were no differences in functional outcome or mortality between the groups, the trial favours the use of subdural irrigation.

FUNDING

State Fund for University Level Health Research (Helsinki University Hospital), Finska Läkaresällskapet, Medicinska Understödsföreningen Liv och Hälsa, and Svenska Kulturfonden.

Comparative analysis of surgical techniques in the management of chronic subdural hematomas and risk factors for poor outcomes

Chronic subdural hematomas (CSDH) are increasingly prevalent, especially among the elderly. Surgical intervention is essential in most cases. However, the choice of surgical technique, either craniotomy or burr-hole opening, remains a subject of debate. Additionally, the risk factors for poor long-term outcomes following surgical treatment remain poorly described. This article presents a 10-year retrospective cohort study conducted at a single center that aimed to compare the outcomes of two common surgical techniques for CSDH evacuation: burr hole opening and minicraniotomy. The study also identified risk factors associated with poor long-term outcome, which was defined as an mRS score ≥ 3 at 6 months. This study included 582 adult patients who were surgically treated for unilateral CSDH. Burr-hole opening was performed in 43% of the patients, while minicraniotomy was performed in 57%. Recurrence was observed in 10% of the cases and postoperative complications in 13%. The rates of recurrence, postoperative complications, death and poor long-term outcome did not differ significantly between the two surgical approaches. Multivariate analysis identified postoperative general complications, recurrence, and preoperative mRS score ≥ 3 as independent risk factors for poor outcomes at 6 months. Recurrence contribute to a poorer prognosis in CSDH. Nevertheless, use burr hole or minicraniotomy for the management of CSDH showed a similar recurrence rate and no significant differences in post-operative outcomes. This underlines the need for a thorough assessment of patients with CSHD and the importance of avoiding their occurrence, by promoting early mobilization of patients. Future research is necessary to mitigate the risk of recurrence, regardless of the surgical technique employed.

The Influence of Coagulopathy on Radiographic and Clinical Outcomes in Patients Undergoing Middle Meningeal Artery Embolization as Standalone Treatment for Non-acute Subdural Hematomas

Middle meningeal artery embolization (MMAE) is emerging as a safe and effective standalone intervention for non-acute subdural hematomas (NASHs); however, the risk of hematoma recurrence after MMAE in coagulopathic patients is unclear. To characterize the impact of coagulopathy on treatment outcomes, we analyzed a multi-institutional database of patients who underwent standalone MMAE as treatment for NASH. We classified 537 patients who underwent MMAE as a standalone intervention between 2019 and 2023 by coagulopathy status. Coagulopathy was defined as use of anticoagulation/antiplatelet agents or pre-operative thrombocytopenia (platelets <100,000/μL). Demographics, pre-procedural characteristics, in-hospital course, and patient outcomes were collected. Thrombocytopenia, aspirin use, antiplatelet agent use, and anticoagulant use were assessed using univariate and multivariate analyses to identify any characteristics associated with the need for rescue surgical intervention, mortality, adverse events, and modified Rankin Scale score at 90-day follow-up. Propensity score-matched cohorts by coagulopathy status with matching covariates adjusting for risk factors implicated in surgical recurrence were evaluated by univariate and multivariate analyses. Minimal differences in pre-operative characteristics between patients with and those without coagulopathy were observed. On unmatched and matched analyses, patients with coagulopathy had higher rates of requiring subsequent surgery than those without (unmatched: 9.9% vs. 4.3%; matched: 12.6% vs. 4.6%; both p < 0.05). On matched multivariable analysis, patients with coagulopathy had an increased odds ratio (OR) of requiring surgical rescue (OR 3.95; 95% confidence interval [CI] 1.68-9.30; p < 0.01). Antiplatelet agent use (ticagrelor, prasugrel, or clopidogrel) was also predictive of surgical rescue (OR 4.38; 95% CI 1.51-12.72; p = 0.01), and patients with thrombocytopenia had significantly increased odds of in-hospital mortality (OR 5.16; 95% CI 2.38-11.20; p < 0.01). There were no differences in follow-up radiographic and other clinical outcomes in patients with and those without coagulopathy. Patients with coagulopathy undergoing standalone MMAE for treatment of NASH may have greater risk of requiring surgical rescue (particularly in patients using antiplatelet agents), and in-hospital mortality (in thrombocytopenic patients).

Comparative efficacy of dexamethasone versus surgery for chronic subdural hematoma: A systematic review and meta-analysis

OBJECTIVE

To assess the comparative efficacy of dexamethasone (DXM) as monotherapy in comparison to surgery among the patients of chronic subdural hematoma (CSDH).

METHODS

We searched MEDLINE, PUBMED, EMBASE, and Cochrane Central Register of Controlled Trials databases from inception till September 2023. Data was extracted, pooled and analyzed from all the studies that assessed the comparative efficacy of DXM as monotherapy in contrast with surgery as the primary treatment of CSDH.

RESULTS

A total of 6 studies involving 704 patients were included in our meta-analysis. Comparison of surgery to DXM revealed there was no statistically significant difference between the two groups regarding mortality [RR=1.09; 95% CI; 0.52-2.28 P = 0.83]. However, a significantly higher incidence of secondary surgical intervention was observed in the DXM group [RR 4.24; 95% CI; 2.06-8.71 P < 0.0001]. No significant difference in performance was observed in terms of poor postoperative outcomes within hospital stay [RR 1.12, 95% CI, 0.40-3.19 P=0.83] and at 6 months [RR 0.92, 95%CI, 0.40-2.13 P=0.85].

CONCLUSION

DXM had a significantly higher incidence of secondary surgical intervention. However, there was no difference regarding mortality and other safety outcomes between surgery and DXM for the patients with CSDH. Observational studies showed that DXM was associated with a lower risk of poor postoperative outcomes within hospital stay and had shorter duration of hospital stay, but the recurrence rate was lower in the surgery group.

Assessment of Surgical Treatment and Outcome of Chronic Subdural Hematoma at University of Gondar Comprehensive Specialized Hospital, a one Year Prospective Study

OBJECTIVE

Chronic subdural hematomas (CSDHs) are a relatively common condition defined as an abnormal collection of blood and its break down products in the subdural space, usually accompanied by a history of preceding mild head trauma. Surgical management remains the mainstay of treatment. The objective of this study was to assess the surgical treatment outcome of patients operated on for CSDH at University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia. This comprehensive novel study serves as a benchmark for assessing therapeutic outcomes among patients with CSDH in the context of Ethiopia.

METHODS

Institution-based prospective observational study was conducted among patients operated on for symptomatic CSDH at University of Gondar Comprehensive Specialized Hospital from January 1, 2023, to December 31, 2023 G C.

RESULT

A total of 107 patients (70 males (65.4%) and 37 females (34.6%) with a male to female ration of 1.9:1 and mean age of 62.4 and a standard deviation of 13.7 (range from 23 to 92) were studied. Fifyt-one (47.7%) of the patients had a history of antecedent trauma. In terms of clinical symptoms, 86 (80.4%) patients had weakness as the chief complaint, followed by headache in 81 (75.7%). Among complications, recurrence is the most common, which was seen in 16 (15%) patients, followed by altered mental status (confusion, delirium) in 18 (16.8%) patients. The mean duration of the hospital stay was 6 days, with a standard deviation of 4 days. The majority of the patients had a good recovery with the resumption of normal life: 92 (86%), 10 (9.3%) patients had moderate disability, were disabled but independent, 2 (1.8%) patients had severe disability, were dependent on daily support, and 3 (2.8%) patients died.

CONCLUSION

CSDHs are a relatively common condition characterized by an abnormal collection of blood. Antecedent trauma is the usual risk factor. Complication can happen following surgical intervention; however, patients with CSDH generally have a good prognosis.

Underwater versus Closed Drainage System for Surgical Treatment of Chronic Subdural Hematoma

OBJECTIVES

Chronic subdural hematoma (CDH) is a prevalent condition in neurosurgery. Standard care includes surgical evacuation with drainage of residual subdural cavity. We hypothesized that effective and timely drainage of subdural space may improve clinical and radiological outcomes. This study was conducted to compare the effectiveness of standard closed drainage and underwater drainage.

METHODS

Medical data of 300 surgically treated chronic subdural hematoma CDH patients were retrospectively collected and analyzed. The patients were divided into two 2 groups: Group I with underwater drainage, and Group II with closed drainage. Groups were compared in terms of gender, age, complication rates, recurrence rates, seizure rates, and length of hospital stay.

RESULTS

Underwater drainage was found superior to closed system by all clinical and radiographic parameters. The recurrence rate was significantly lower in Group I (2%) compared to with Group II (10%). Subdural empyema was observed in 10 patients in Group II and none in Group I. The seizure rate was higher in Group II (18%) compared to with Group I (5%). Postoperative pneumocephalus rates was were 20% in Group I and 54% in Group II. The length of hospital stay was 6±2.6 days in Group I and 8.9±6.1 days in Group II. The length of intensive care unit (ICU) stay was 0.6±1.12 days in Group I and 2.7±5 days in Group II. A minority (5%) of the patients in Group II required reoperation due to recurrence.

CONCLUSIONS

The use of underwater system significantly the reduces the rates of pneumocephalus, seizures, infection, and recurrence. Additional benefits are shorter intensive care unit ICU and total hospital stays.

ARISE I Consensus Statement on the Management of Chronic Subdural Hematoma

ARISE (Aneurysm/AVM/cSDH Roundtable Discussion With Industry and Stroke Experts) organized a one-and-a-half day meeting and workshop and brought together representatives from academia, industry, and government to discuss the most promising approaches to improve outcomes for patients with chronic subdural hematoma (cSDH). The emerging role of middle meningeal artery embolization in clinical practice and the design of current and potential future trials were the primary focuses of discussion. Existing evidence for imaging, indications, agents, and techniques was reviewed, and areas of priority for study and key questions surrounding the development of new and existing treatments for cSDH were identified. Multiple randomized, controlled trials have met their primary efficacy end points, providing high-level evidence that middle meningeal artery embolization is a potent adjunctive therapy to the standard (surgical and nonsurgical) management of neurologically stable cSDH patients in terms of reducing rates of disease recurrence. Pooled data analyses following the formal conclusion and publication of these trials will form a robust foundation upon which guidelines can be strengthened for cSDH treatment modalities and optimal patient selection, as well as delineate future lines of investigation.

"Curtain-fall" technique for cerebrospinal fluid leak prevention after removal of intradural drainage. Technical note: application in chronic subdural hematoma surgery

OBJECTIVE

Chronic subdural hematoma (CSDH) is frequently met in neurosurgical practice and often need urgent surgical treatment in case of neurological deterioration. Different surgical approaches to evacuate CSDH are described in the literature. In our experience, an external drainage system is crucial in order to avoid recurrences. We recently encountered a case of subcutaneous CSF collection after drainage removal. Thus, we developed a simple surgical technique to prevent postoperative CSF leak after subdural drainage system removal.

METHOD

We have developed a technique in which the periosteum is harvested during the surgery prior to the evacuation of the hemorrhage and fixed with sutures on the uncut dura mater opposite and laterally to the exit of the catheter exiting the dural hole caused by the passage of the Jackson-Pratt subdural drainage system. When the drainage catheter is removed, the flap, partially held by the sutures, falls over the hole avoiding CSF leakage. By using this technique, the small dural hole will be covered with the periosteum allowing for natural closure and wound healing hence preventing CSF leakage.

RESULTS

This technique was successfully employed in 21 patients who didn't develop postoperative CSF leakage following CSDH evacuation and removal of subdural drainage system.

CONCLUSION

In this technical note, we describe a safe dura closure technique that we developed to help reduce the risk of postoperative CSF leakage following subdural drainage removal, which can, however, also be applied in all surgeries in which a catheter is placed in the subdural space.

Middle meningeal artery embolization for chronic subdural hematoma: A single-center experience and predictive modeling of outcomes

BACKGROUND

Remarkable interest is rising around middle meningeal artery embolization (MMAE) as an emerging alternative therapy for chronic subdural hematoma (cSDH). The study aims to highlight a large center experience and the variables associated with treatment failure and build experimental machine learning (ML) models for outcome prediction.

MATERIAL AND METHODS

A 2-year experience in MMAE for managing patients with chronic subdural hematoma was analyzed. Descriptive statistical analysis was conducted using imaging and clinical features of the patients and cSDH, which were subsequently used to build predictive models for the procedure outcome. The modeling evaluation metrics were the area under the ROC curve and F1-score.

RESULTS

A total of 100 cSDH of 76 patients who underwent MMAE were included with an average follow-up of 6 months. The intervention had a per procedure success rate of 92%. Thrombocytopenia had a highly significant association with treatment failure. Two patients suffered a complication related to the procedure. The best performing machine learning models in predicting MMAE failure achieved an ROC-AUC of 70%, and an F1-score of 67%, including all patients with or without surgical intervention prior to embolization, and an ROC-AUC of 82% and an F1-score of 69% when only patients who underwent upfront MMAE were included.

CONCLUSION

MMAE is a safe and minimally invasive procedure with great potential in transforming the management of cSDH and reducing the risk of surgical complications in selected patients. An ML approach with larger sample size might help better predict outcomes and highlight important predictors following MMAE in patients with cSDH.

An Algorithm for Treatment of Symptomatic Chronic Subdural Hematomas

INTRODUCTION

Although chronic subdural hematoma (CSDH) is a common neurosurgical disease, there is a lack of algorithms for the treatment of asymptomatic and symptomatic CSDH. The purpose of this article is to describe an algorithm developed using our institutional experience for the treatment of symptomatic CSDH that aims to decrease symptoms and/or hematoma size or to completely resolve both. Our algorithm for treatment of symptomatic CSDH includes subdural drain (SDD) placement via twist-drill craniostomy (TDC) as the first-line treatment, followed by supplemental tissue plasminogen activator (tPA) as second-line treatment, with possible middle meningeal artery embolization (MMAE), followed by craniotomy as the last therapeutic option. This study investigated the efficacy of our institution's algorithm in treating symptomatic CSDH.

METHODS

A retrospective study was conducted from 2019 to 2023 identifying patients with CSDH treated with TDC. Electronic medical records were used to gather patient demographics, clinical presentation, radiographic findings, treatment modalities, and clinical outcomes.

RESULTS

There were a total of 109 patients with 128 SDD placements. All 109 patients underwent TDC; among them, 37 patients received tPA instillation with three patients requiring craniotomy. Factors including age, gender, race, mechanism of injury, blood thinner usage, Glasgow Coma Scale (GCS), neurologic exam, thickness of CSDH, and midline shift were comparable for all patients regardless of treatment received. The mean number of neomembranes was higher in patients who eventually required craniotomy (4.5) compared to those treated with TDC only (1.8) and TDC+tPA (2.1) (p=0.0035). There was a greater mean hematoma drainage in patients who received tPA instillation without craniotomy (586.7 mL) than those treated with TDC only (293.0 mL) (p<0.0001). Clinical improvement was found in 52/72 patients (72.2%) treated with TDC only, 23/34 patients (67.6%) treated with TDC+tPA only, and 0/3 patients (0.0%) treated with TDC+tPA+craniotomy. Radiographic improvement in mean thickness of CSDH and midline shift, respectively, was found in patients treated with TDC only (p<0.0001; p<0.0001) and TDC+tPA (p<0.0001; p<0.0001) but not in TDC+tPA+craniotomy (p=0.1494; p=0.0762). There were also fewer neomembranes after TDC+tPA treatment only (2.1 vs. 0.5, p<0.0001). Seven patients were readmitted that did not follow the algorithm and only patients treated following the algorithm showed clinical and radiographic improvement.

CONCLUSIONS

Using our institutional algorithm, our study demonstrates successful clinical outcomes in treating symptomatic CSDH and recurrent CSDH with minimally invasive therapeutic interventions including SDD via TDC and tPA, thereby minimizing the utilization of more invasive interventions including craniotomy.

A novel swine model of selective middle meningeal artery catheterization and embolization

BACKGROUND

Middle meningeal artery (MMA) embolization is a promising intervention as a stand-alone or adjunct treatment to surgery in patients with chronic subdural hematomas. There are currently no large animal models for selective access and embolization of the MMA for preclinical evaluation of this endovascular modality. Our objective was to introduce a novel in vivo model of selective MMA embolization in swine.

METHODS

Diagnostic cerebral angiography with selective microcatheter catheterization into the MMA was performed under general anesthesia in five swine. Anatomical variants in arterial meningeal supply were examined. In two animals, subsequent embolization of the MMA with a liquid embolic agent (Onyx-18) was performed, followed by brain tissue harvest and histological analysis.

RESULTS

The MMA was consistently localized as a branch of the internal maxillary artery just distal to the origin of the ascending pharyngeal artery. Additional meningeal supply was observed from the external ophthalmic artery, although not present consistently. MMA embolization with Onyx was technically successful and feasible. Histological analysis showed Onyx material within the MMA lumen.

CONCLUSIONS

Microcatheter access into the MMA in swine with liquid embolic agent delivery represents a reproducible model of MMA embolization. Anatomical variations in the distribution of arterial supply to the meninges exist. This model has a potential application for comparing therapeutic effects of various embolic agents in a preclinical setting that closely resembles the MMA embolization procedure in humans.

Efficacy and safety of bedside percutaneous three-millimeter twist-drill trephination under local anesthesia-a retrospective study of 1000 patients

PURPOSE

Percutaneous 3-mm twist-drill trephination (TDT) under local anesthesia as a bedside operative technique is an alternative to the conventional open surgical trephination in the operating theatre. The aim of this study was to verify the efficacy and safety of this minimal invasive procedure.

METHODS

This retrospective study comprises 1000 patients who were treated with TDT under local anesthesia at bedside due to chronic subdural hematoma (cSDH), intracerebral hemorrhage (ICH), and hydrocephalus (HYD) as a result of subarachnoid hemorrhage or non-hemorrhagic causes, increased intracranial pressure (IIP) in traumatic brain injury or non-traumatic brain edema, and other pathologies (OP) requiring drainage. Medical records, clinical outcome, and results of pre- and postoperative computed tomography (CT) and/or magnetic resonance tomography (MRT) were analyzed.

RESULTS

Indications for TDT were cSDH (n = 275; 27.5%), ICH (n = 291; 29.1%), HYD (n = 316; 31.6%), IIP (n = 112; 11.2%), and OP (n = 6; 0.6%). Overall, primary catheter placement was sufficient in 93.8% of trephinations. Complication rate was 14.1% and mainly related to primary catheter malposition (6.2%), infections (5.2%), and secondary hemorrhage (2.7%); the majority of which were clinically inapparent puncture channel bleedings not requiring surgical intervention. The revision rate was 13%.

CONCLUSIONS

Bedside TDT under local anesthesia has proven to be an effective and safe alternative to the conventional burr-hole operative technique as usually performed under general anesthesia in the operation theatre, and may be particularly useful in emergency cases as well as in elderly and multimorbid patients.

The value of computed tomography texture analysis in identifying chronic subdural hematoma patients with a good response to polytherapy

This study aimed to investigate the predictive factors of therapeutic efficacy for chronic subdural hematoma (CSDH) patients receiving atorvastatin combined with dexamethasone therapy by using clinical imaging characteristics in conjunction with computed tomography (CT) texture analysis (CTTA). Clinical imaging characteristics and CT texture parameters at admission were retrospectively investigated in 141 CSDH patients who received atorvastatin combined with dexamethasone therapy from June 2019 to December 2022. The patients were divided into a training set (n = 81) and a validation set (n = 60). Patients in the training data were divided into two groups based on the effectiveness of the treatment. Univariate and multivariate analyses were performed to assess the potential factors that could indicate the prognosis of CSDH patients in the training set. The receiver operating characteristic (ROC) curve was used to analyze the predictive efficacy of the significant factors in predicting the prognosis of CSDH patients and was validated using a validation set. The multivariate analysis showed that the hematoma density to brain parenchyma density ratio, singal min (minimum) and singal standard deviation of the pixel distribution histogram, and inhomogeneity were independent predictors for the prognosis of CSDH patients based on atorvastatin and dexamethasone therapy. The area under the ROC curve between the two groups was between 0.716 and 0.806. As determined by significant factors, the validation's accuracy range was 0.816 to 0.952. Clinical imaging characteristics in conjunction with CTTA could aid in distinguishing patients with CSDH who responded well to atorvastatin combined with dexamethasone.

Retrospective Analysis of Risk Factors for Recurrence of Chronic Subdural Haematoma after Surgery

(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.

Multimodality management for chronic subdural hematoma in China: protocol and characteristics of an ambidirectional, nationwide, multicenter registry study

BACKGROUND

Despite its prevalence, there is ongoing debate regarding the optimal management strategy for chronic subdural hematoma (CSDH), reflecting the variability in clinical presentation and treatment outcomes. This ambidirectional, nationwide, multicenter registry study aims to assess the efficacy and safety of multimodality treatment approaches for CSDH in the Chinese population.

METHODS/DESIGN

A multicenter cohort of CSDH patients from 59 participating hospitals in mainland China was enrolled in this study. The treatment modalities encompassed a range of options and baseline demographics, clinical characteristics, radiographic findings, and surgical techniques were documented. Clinical outcomes, including hematoma resolution, recurrence rates, neurological status, and complications, were assessed at regular intervals during treatment, 3 months, 6 months, 1 year, and 2 years follow-up.

RESULT

Between March 2022 and August 2023, a comprehensive cohort comprising 2173 individuals who met the criterion was assembled across 59 participating clinical sites. Of those patients, 81.1% were male, exhibiting an average age of 70.12 ± 14.53 years. A historical record of trauma was documented in 48.0% of cases, while headache constituted the predominant clinical presentation in 58.1% of patients. The foremost surgical modality employed was the burr hole (61.3%), with conservative management accounting for 25.6% of cases. Notably, a favorable clinical prognosis was observed in 88.9% of CSDH patients at 3 months, and the recurrence rate was found to be 2.4%.

CONCLUSION

This registry study provides critical insights into the multimodality treatment of CSDH in China, offering a foundation for advancing clinical practices, optimizing patient management, and ultimately, improving the quality of life for individuals suffering from this challenging neurosurgical condition.

TRIAL REGISTRATION

ChiCTR2200057179.

Granuloma formation as a late complication of burr-hole surgery for chronic subdural hematoma

BACKGROUND

Surgical treatment remains the mainstream therapeutic regimen for chronic subdural hematoma (CSDH), and burr-hole craniostomy with subdural drainage is the preferable approach. Herein, we reported a case of intracranial granuloma formation as a late complication of burr-hole surgery for CSDH.

CASE PRESENTATION

A 31-year-old man presented with a 1-month history of headache. Head computed tomography (CT) showed a subdural hematoma in the left frontal-temporal-parietal region with significant midline shifting. A burr-hole evacuation of the hematoma with closed-system drainage was performed. CT obtained immediately after the surgery demonstrated that the hematoma was mostly evacuated. Nine months later, he presented to us again due to intermittent headache in the left temporoparietal region. Brain magnetic resonance imaging revealed a space-occupying mass at the site of the original hematoma. A bone-flap craniotomy was performed for resecting the mass. Histopathological examination revealed a granuloma. The microbial cultivation of the resected specimen was negative. The postoperative course was uneventful, and the headache was relieved.

CONCLUSION

Granuloma formation is an extremely rare late complication of burr-hole surgery for CSDH. Physicians involved in the perioperative management of CSDH should be aware of this condition, and bone-flap craniotomy may be warranted.

The Effect of Japanese Herbal Medicines (Kampo) Goreisan and Saireito on the Prevention of Recurrent Chronic Subdural Hematoma: A Prospective Randomized Study

BACKGROUND AND OBJECTIVES

Chronic subdural hematoma (CSDH) sometimes recurs after surgical treatment and requires reoperation. In Japan, Japanese herbal medicines (Kampo), such as Goreisan and Saireito, have been used as adjunctive therapies to prevent the recurrence of CSDH. However, no prospective randomized study has proven the efficacy of Kampo medicine in all patients. To investigate whether Goreisan and Saireito reduce the postoperative recurrence of CSDH in a prospective randomized study.

METHODS

Between April 2017 and July 2019, a total of 118 patients who underwent initial burr hole surgery for CSDH were randomly assigned to the following 3 groups: (1) Goreisan for 3 months (Group G), (2) Saireito for 3 months (Group S), and (3) no medication (Group N). The primary end point was symptomatic recurrence within 3 months postoperatively, and the secondary end point was complications associated with the administration of Kampo medicine.

RESULTS

Among 118 patients, 114 (Group N, n = 39; Group G, n = 37; and Group S, n = 38) were included in our analysis. In this study, byakujutsu (containing Atractylodes rhizome ) Goreisan and Saireito were used, unlike other prospective randomized studies in which sojutsu (containing Atractylodes lancea rhizome) Goreisan was used. The overall recurrence rate was 11.4% (13/114: 10 for Group N, 2 for Group G, and 1 for Group S). The recurrence rate of Group G was significantly lower than that of Group N (5.4% vs 25.6%; P = .043). The recurrence rate of Group S was also significantly lower than that of Group N (2.6% vs 25.6%; P = .02). No patients developed complications associated with the administration of Kampo medicine.

CONCLUSION

This is the first study to show that Kampo medicine reduced the recurrence rate of CSDH in an overall population. This study demonstrated that byakujutsu Goreisan and Saireito may have favorable effects, unlike other studies, because byakujutsu has stronger anti-inflammatory activity than sojutsu.

Featured minimally invasive therapeutic approach for chronic subdural hematoma: Embolization of middle meningeal artery - A narrative review

Chronic subdural hematoma (c-SDH) is a frequent and serious neurological disease. It develops due to hemorrhage to the subdural space, mainly caused by head trauma. The middle meningeal artery (MMA) plays a critical role in the supply of blood to c-SDH. The decision on the type of treatment for c-SDH depends mainly on clinical and imaging evaluation. In cases in which patients are critically ill, the hematoma must be evacuated immediately. For this purpose, surgery is generally accepted as the mainstay of treatment. Among surgical techniques, twist-drill craniotomy, burr-hole craniotomy, and craniotomy are the three most used. The recurrence rate of c-SDH after surgery is an important problem with a rate of up to 30%. The technical success classification embolization of MMA (EMMA) has emerged as an effective and safe option for the treatment of c-SDH, especially those that recur. EMMA is commonly used as an adjunct to surgery or less frequently alone. The technical success of EMMA has been a promising minimal invasive strategy as an alternative or adjunctive therapy to surgical methods. Polyvinyl alcohol is the most widely used among various embolizing agents, including n-butyl cyanoacrylate, coil, and gelatin sponge. EMMA has been shown to prevent the formation or recurrence of c-SDH by eliminating blood flow to the subdural space. Complication rates are low. The large-scale comparative prospective will ensure efficacy and safety. This article aims to highlight the current information about EMMA in patients with c-SDH.

Surgical evacuation for chronic subdural hematoma: Predictors of reoperation and functional outcomes

Background

Although chronic subdural hematoma (CSDH) incidence has increased, there is limited evidence to guide patient management after surgical evacuation.

Objective

To identify predictors of reoperation and functional outcome after CSDH surgical evacuation.

Methods

We identified all patients with CSDH between 2010 and 2018. Clinical and radiographic variables were collected from the medical records. Outcomes included reoperation within 90 days and poor (3-6) modified Rankin Scale score at 3 months.

Results

We identified 461 surgically treated CSDH cases (396 patients). The mean age was 70.1 years, 29.7 % were females, 298 (64.6 %) underwent burr hole evacuation, 152 (33.0 %) craniotomy, and 11 (2.4 %) craniectomy. Reoperation rate within 90 days was 12.6 %, whereas 24.2 % of cases had a poor functional status at 3 months. Only female sex was associated with reoperation within 90 days (OR = 2.09, 95 % CI: 1.17-3.75, P = 0.013). AMS on admission (OR = 5.19, 95 % CI: 2.15-12.52, P < 0.001) and female sex (OR = 3.90, 95 % CI: 1.57-9.70, P = 0.003) were independent predictors of poor functional outcome at 3 months.

Conclusion

Careful management of patients with the above predictive factors may reduce CSDH reoperation and improve long-term functional outcomes. However, larger randomized studies are necessary to assess long-term prognosis after surgical evacuation.

Neuroendoscopic Technique for Septated Chronic Subdural Hematoma: A Retrospective Study

OBJECTIVES

To compare the efficacy of neuroendoscopic hematoma evacuation (NHE) and burr hole craniotomy (BHC) for treating septated chronic subdural hematoma (sCSDH) and analyze the technical advantages of NHE in sCSDH treatment by data analysis.

METHODS

This study recruited 77 patients with sCSDH According to the type of operation, the patients were divided into NHE (n = 45) or BHC (n = 32) groups. Clinical data were retrospectively analyzed to evaluate and compare the efficacy of NHE and BHC for treating sCSDH.

RESULTS

NHE demonstrated higher complete hematoma clearance and postoperative midline recovery rates and shorter subdural drainage and postoperative bed rest durations compared with BHC (P < 0.05). The average NHE time (72.27 ± 18.27 minutes) was longer than that of BHC (54.91 ± 16.04 minutes) (P < 0.05). The average follow-up period was 30.9 (range, 7-51) months. The results revealed that 1 and 12 cases recurred in the NHE (2.2%) and BHC (18.8%) groups, respectively (P < 0.05). Additionally, a statistically significant difference in the Modified Rankin Scale scores of the 2 groups was observed 6 months after the operation (P < 0.05). During the follow-up period, neither group demonstrated any obvious operative complications.

CONCLUSIONS

NHE is more effective than BHC for treating sCSDH and is worth popularizing on a large scale; however, ways to better deal with the outer membrane of hematoma warrant further consideration.

Comparative study on clinical outcomes and cost-effectiveness of chronic subdural hematomas treated by middle meningeal artery embolization and conventional treatment: a national cross-sectional study

BACKGROUND

The authors compared the efficacy and cost-effectiveness of middle meningeal artery embolization (MMAE) and conventional treatment for chronic subdural hematomas (cSDH).

METHODS

The Nationwide Readmissions Database of 9963 patients (27.2% women) with cSDH between 2016 and 2020 was analyzed. Finally, 9532 patients were included (95.7%, treated conventionally; 4.3%, treated with MMAE). Baseline demographics, comorbidities, adverse events, treatment strategies, and outcomes were compared between patients treated with MMAE and conventional treatment. After propensity score matching, the authors compared primary outcomes, including the 90-day treatment rate, functional outcome, length of hospital stays, and cost. A Markov model estimated lifetime costs and quality-adjusted life years (QALYs) associated with different treatments. The incremental cost-effectiveness ratio (ICER) was calculated to evaluate the base-case scenario. One-way, two-way, and probabilistic sensitivity analyses were performed to evaluate the uncertainty in the results.

RESULTS

After propensity score matching, MMAE had a lower 90-day retreatment rate (2.6 vs. 9.0%, P =0.001), shorter length of hospital stays (4.61±6.19 vs. 5.73±5.76 days, P =0.037), similar functional outcomes compared (favorable outcomes, 80.9 vs. 74.8%, P =0.224) but higher costs ($119 757.71±90 378.70 vs. $75 745.55±100 701.28, P <0.001) with conventional treatment. MMAE was associated with an additional cost of US$19 280.0 with additional QALY of 1.3. Its ICER was US$15199.8/QALY.

CONCLUSION

MMAE is more effective in treating cSDH than conventional treatment. Based on real-world data, though MMAE incurs higher overall costs, the Markov model showed it to be cost-effective compared to conventional treatment under the American healthcare system. These comparative and economic analyses further support the consideration of a paradigm shift in cSDH treatment.

Factors for predicting recurrence after burr hole drainage for chronic subdural hematoma: a retrospective study

Chronic subdural hematoma (SDH) is a common disease in the neurosurgical field, and hematoma drainage through burr hole trephination has been widely considered the optimal treatment for SDH. Despite numerous investigations aimed at predicting recurrence rates and associated factors, studies have demonstrated inconsistent results. In this study, we aimed to comprehensively determine the predictive factors of chronic SDH recurrence in surgically treated patients. We retrospectively evaluated 578 consecutive patients who underwent single burr hole surgery for chronic SDH at our institute between January 2008 and December 2021. Various clinical and radiological factors in patients with and without recurrence were compared using univariate and multivariate logistic regression analyses. A total of 438 patients (531 hemispheres) were analyzed. Fifty-four (10.17%) of the 531 hemispheres had recurrence of chronic SDH within 6 months. Male sex (adjusted odds ratio (aOR) = 3.48; 95% confidence interval (CI), 1.42-8.49), bilateral hematomas (aOR = 2.14; 95% CI, 1.05-4.35), laminar hematoma type (aOR = 2.87; 95% CI, 1.23-6.71), > 30-cm3 volume of postoperative residual hematoma (aOR = 2.99; 95% CI, 1.01-8.83), and preoperative blood glucose level of ≥ 150 mg/dL (aOR = 2.11; 95% CI, 1.10-4.05) were identified as independent factors associated with recurrence in multivariate logistic regression analysis. The present study revealed that male patients and those who had bilateral hematomas, laminar hematoma type, a large volume of hematoma after surgery, and a high preoperative blood glucose level had a higher probability of experiencing recurrent chronic SDH. We recommend close monitoring of patients 6 months postoperatively to detect subsequent chronic SDH recurrence.

Balancing Bleeding Risk and Thromboembolic Complications in Elderly Chronic Subdural Hematoma Patients Undergoing Burr Hole Trephination : A Multicenter Retrospective Cohort Study and Literature Review

OBJECTIVE

Chronic subdural hematoma (CSDH) patients using antithrombotic agents (AT) at high risk for cardiovascular disease are increasing. The authors aimed to analyze the factors influencing outcome by targeting patients using AT and to establish a desirable treatment strategy.

METHODS

A retrospective analysis was performed on data from 462 patients who underwent burr hole trephination (BHT) surgery for CSDH at five hospitals from March 2010 to June 2021. Outcomes included incidence of postoperative acute bleeding, recurrence rate, and morbidity or mortality rate. Patients were divided into the following four groups based on their history of AT use : no AT. Only antiplatelet agents (AP), only anticoagulants (AC), both of AP and AC. In addition, a concurrent literature review was conducted alongside our cohort study.

RESULTS

Of 462 patients, 119 (119/462, 25.76%) were using AT. AP prescription did not significantly delay surgery (p=0.318), but AC prescription led to a significant increase in the time interval from admission to operation (p=0.048). After BHT, AP or AC intake significantly increased the period required for an in-dwelling drain (p=0.026 and p=0.037). The use of AC was significantly related to acute bleeding (p=0.044), while the use of AP was not (p=0.808). Use of AP or AC had no significant effect on CSDH recurrence (p=0.517 and p=1.000) or reoperation (p=0.924 and p=1.000). Morbidity was not statistically correlated with use of either AP or AC (p=0.795 and p=0.557, respectively), and there was no significant correlation with mortality for use of these medications (p=0.470 and p=1.000).

CONCLUSION

Elderly CSDH patients may benefit from maintenance of AT therapy during BHT due to reduced thromboembolic risk. However, the use of AC necessitates individualized due to potential postoperative bleeding. Careful post-operative monitoring could mitigate prognosis and recurrence impacts.

Risk factors for recurrence of chronic subdural hematoma after surgical evacuation: a systematic review and meta-analysis

Chronic subdural hematoma (CSDH) is a common neurosurgical condition. Surgical evacuation has remained the primary treatment despite many advancements in the endovascular field. Regardless, recurrence requiring reoperation is commonly observed during the postoperative follow-up. Herein, we aimed to investigate risk factors for recurrence after surgical evacuation. A review of MEDLINE, EMBASE, Web of Science, and Scopus was conducted using the designed search string. Studies were reviewed based on the predefined eligibility criteria. Data regarding sixty potential risk factors along with operational information were extracted for analysis. A meta-analysis using the random-effect model was conducted, and each risk factor affecting the postoperative recurrence of CSDH was then evaluated and graded. A total of 198 records met the eligibility criteria. A total number of 8523 patients with recurrent CSDH and 56,096 with non-recurrent CSDH were included in the study. The recurrence rate after surgical evacuation was 12%. Fifteen preoperative, nine radiologic, four hematoma-related, and three operative and postoperative factors were associated with recurrence. Risk factors associated with recurrence after surgical evacuation are important in neurosurgical decision-making and treatment planning. Found risk factors in this study may be used as the basis for pre-operative risk assessment to choose patients who would benefit the most from surgical evacuation.

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

OBJECTIVES

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Incidence, therapy, and outcome in the management of chronic subdural hematoma in Switzerland: a population-based multicenter cohort study

Background

Chronic subdural hematoma (cSDH) is a disease affecting mainly elderly individuals. The reported incidence ranges from 2.0/100,000 to 58 per 100,000 person-years when only considering patients who are over 70 years old, with an overall incidence of 8.2-14.0 per 100,000 persons. Due to an estimated doubling of the population above 65 years old between 2000 and 2030, cSDH will become an even more significant concern. To gain an overview of cSDH hospital admission rates, treatment, and outcome, we performed this multicenter national cohort study of patients requiring surgical treatment of cSDH.

Methods

A multicenter cohort study included patients treated in 2013 in a Swiss center accredited for residency. Demographics, medical history, symptoms, and medication were recorded. Imaging at admission was evaluated, and therapy was divided into burr hole craniostomy (BHC), twist drill craniostomy (TDC), and craniotomy. Patients' outcomes were dichotomized into good (mRS, 0-3) and poor (mRS, 4-6) outcomes. A two-sided t-test for unpaired variables was performed, while a chi-square test was performed for categorical variables, and a p-value of <0.05 was considered to be statistically significant.

Results

A total of 663 patients were included. The median age was 76 years, and the overall incidence rate was 8.2/100,000. With age, the incidence rate increased to 64.2/100,000 in patients aged 80-89 years. The most prevalent symptoms were gait disturbance in 362 (58.6%) of patients, headache in 286 (46.4%), and focal neurological deficits in 252 (40.7%). CSDH distribution was unilateral in 478 (72.1%) patients, while 185 presented a bilateral hematoma with no difference in the outcome. BHC was the most performed procedure for 758 (97.3%) evacuations. CSDH recurrence was noted in 104 patients (20.1%). A good outcome was seen in almost 81% of patients. Factors associated with poor outcomes were age, GCS and mRS on admission, and the occurrence of multiple deficits present at the diagnosis of the cSDH.

Conclusion

As the first multicenter national cohort-based study analyzing the disease burden of cSDH, our study reveals that the hospital admission rate of cSDH was 8.2/100,000, while with age, it rose to 64.2/100,000. A good outcome was seen in 81% of patients, who maintained the same quality of life as before the surgery. However, the mortality rate was 4%.

A Prospective Study of the Effect and Safety of Atorvastatin on the Recurrence of Chronic Subdural Hematoma after Burr Hole Surgery

Introduction  Chronic subdural hematoma (CSDH) is a common neurosurgical condition. Recent studies showed efficacy of atorvastatin in reducing the requirement of surgical treatment. This study aimed to evaluate the efficacy and safety of atorvastatin in reducing the recurrence of CSDH after burr hole surgery. Methods  This prospective study included patients with CSDH who underwent burr hole surgery. Atorvastatin at 20 mg per day was administered to all patients for 4 weeks postoperatively. The major outcome was the recurrence rate of CSDH at 8 weeks following the operation. Results  Seventy-three patients who completed the 4-week course of atorvastatin were included. The mean age was 73.9 years. The most common cause of CSDH was falling. The mean hematoma volume was 106.3 mL. There was no adverse effect of atorvastatin in all of 73 patients. During the 8-week postoperative period, recurrent CSDH was found in 2 of 73 (2.7%) patients. In a comparison of the recurrence rate of CSDH between patients with use of atorvastatin from the present and previous studies (2.6-4.8%), and patients without use of atorvastatin from previous studies (9.8-19%), a marked reduction in recurrent CSDH after burr hole surgery was found in patients with use of atorvastatin. Conclusion  An administration of atorvastatin of 20 mg daily for 4 weeks following burr hole surgery is safe and may be helpful in reducing the recurrence rate of CSDH after burr hole surgery.

The Use of Adjuvant Dexamethasone in Chronic Subdural Hematoma After Surgery

OBJECTIVE

The use of oral anticoagulants in elderly patients is a predisposing factor in developing a subdural hematoma (SDH). The surgical option is often the standard approach but can be accompanied by complications. In this study, we hypothesized that dexamethasone administration after surgery would positively affect subdural change and subdural size in the second week.

MATERIALS AND METHODS

Within the scope of this prospective research, 66 individuals who underwent surgical intervention for chronic subdural hematoma (CSH) at the neurosurgery department either as an outpatient or under emergency circumstances have been enrolled in the study. During the examination, the patients were questioned about the traumatic incident, the localization of injury, and the utilization of anticoagulant and antiplatelet medications. The Glasgow Coma Scale (GCS) was administered to all patients to assess neurological deficits. Computed tomography (CT) was utilized to determine the characteristics of the hematoma.

RESULTS

A total of 66 patients, 22 (33.3%) using and 44 (66.6%) not using dexamethasone, were included in the study. Analysis of variance (ANOVA) indicated that a statistical difference was achieved in the second week after the operation (p<0.043). During the examination of subdural dimensions after the operation and in the second postoperative week, a difference was detected between the radiological membrane and subdural dimensions. A statistically significant correlation was found between anticoagulation and the type of hematoma (p<0.025).

CONCLUSION

Regarding the outcomes of this research, we can conclude that dexamethasone was not associated with any adverse events. Additionally, dexamethasone could leverage reoperation prevention for the elderly with various comorbidities.

Comparison of Burr-Hole Craniostomy versus Twist-Drill Craniostomy Operations for Patients with Chronic Subdural Hematoma: A Systematic Review and Network Meta-Analysis

BACKGROUND

Chronic subdural hematoma (CSDH) represents one of the most common neurologic disorders in the elderly. However, the optimum surgical option remains questionable. This study aims to compare the safety and efficacy of single burr-hole craniostomy (sBHC), double burr-hole craniostomy (dBHC), and twist-drill craniostomy (TDC) in patients with CSDH.

METHODS

We searched PubMed, Embase, Scopus, Cochrane, and Web of Science until October 2022 for prospective trials. Primary outcomes comprised recurrence and mortality. The analysis was performed using R software, and the results were reported as risk ratio (RR) and 95% confidence interval (CI).

RESULTS

Data from 11 prospective clinical trials were included in this network meta-analysis. We found that dBHC significantly decreased recurrence and reoperation rates compared with TDC (RR = 0.55, CI, 0.33-0.90 and RR = 0.48, CI, 0.24-0.94, respectively). However, sBHC showed no difference compared with dBHC and TDC. There was no significant difference among dBHC, sBHC, and TDC regarding the hospitalization duration, complication rates, mortality, and cured rates.

CONCLUSIONS

dBHC seems to be the best modality for CSDH compared with sBHC and TDC. It showed significantly less recurrence and reoperation rates compared with TDC. On the other hand, dBHC showed no significant difference with the other comparators regarding complication, mortality, and cure rates in addition to the hospitalization duration.

Comparison of different surgical techniques for chronic subdural hematoma: a network meta-analysis

Background

Chronic subdural hematoma (CSDH) is a neurosurgical condition with high prevalence. Many surgical approaches are recommended for treating CSDH, but there needs to be a consensus on the optimal technique. This network meta-analysis (NMA) compared the efficacy and safety of different surgical treatments for CSDH.

Methods

Electronic databases, including PubMed, Embase, and the Cochrane Library, were searched for relevant studies up to February 2023. An NMA was performed to compare the outcomes of patients with CSDH treated by single-hole or double-hole craniotomy (SBHC and DBHC, respectively), twist-drill craniotomy (TDC), mini-craniotomy, and craniotomy. The NMA protocol was registered at INPLASY (registration no. 202320114).

Results

The NMA included 38 studies with 7,337 patients. For efficacy outcomes, DBHC showed the highest surface under the cumulative ranking area (SUCRA) values for recurrence (96.3%) and reoperation (87.4%) rates. DBHC differed significantly from mini-craniotomy in recurrence rate (odds ratio [OR] = 0.58, 95% confidence interval [CI]: 0.35, 0.97) and from SBHC (OR = 0.48, 95% CI: 0.25, 0.91) and TDC (OR = 0.40, 95% CI: 0.20, 0.82) in reoperation rate. For operative time, TDC was superior to SBHC (mean difference [MD] = -2.32, 95% CI: -3.78 to -0.86), DBHC (MD = -3.61, 95% CI: -5.55, -1.67), and mini-craniotomy (MD = -3.39, 95% CI: -5.70, -1.08). Patients treated by TDC had a shorter hospital stay than those treated by SBHC (MD = -0.82, 95% CI: -1.51, -0.12). For safety outcomes, there were no significant differences between groups in mortality and complication rates; however, mini-craniotomy (79.8%) and TDC (78.1%) had the highest SUCRAs.

Conclusion

DBHC may be the most effective surgical treatment for CSDH based on the low recurrence and reoperation rates, although all examined techniques were relatively safe.

Systematic review registration

https://inplasy.com/inplasy-2023-2-0114/.

Biofluid Biomarkers in the Prognosis of Chronic Subdural Hematoma: A Systematic Scoping Review

The present systematic scoping review aimed at mapping and analyzing the available literature on biological fluid (biofluid) biomarkers showing promise in the prediction of chronic subdural hematoma (cSDH) recurrence and the prognosis of neurological/functional patient outcome. Twenty-three studies published between 2003 and 2023 investigating a diverse range of biomarkers in hematoma fluid and/or the circulation in 3749 patients were included. Immune cell populations and inflammatory/anti-inflammatory cytokines comprised the most studied category of biomarkers displaying significant findings. A notable time trend in biomarker studies was a recent shift in research focus towards the analysis of circulating biomarkers. Several biomarkers were indicated as independent predictors of cSDH recurrence and/or functional/neurological outcome, including circulating fibrinogen degradation products (FDP), brain natriuretic peptide (BNP-1) and high-density lipoprotein (HDL), as well as blood urea nitrogen (BUN) and the ratios of blood neutrophil to lymphocyte (NLR) or red blood cell distribution width to platelet count (RPR). While studies on cSDH prognostic biomarkers have gained, in recent years, momentum, additional multicenter prospective studies are warranted to confirm and extend their findings. The identification of prognostic biofluid biomarkers in cSDH is an active field of research that may provide future tools, guiding clinical decisions and allowing for the design of treatments based on risk stratification.

Effectiveness of Burr Hole Sizes on Midline Shift and Hematoma Thickness in the Treatment of Chronic Subdural Hematoma

BACKGROUND

The aim of our study was to investigate the effect of the burr hole width on the postoperative chronic subdural hematoma (CSH) thickness and midline shift radiologically.

METHODS

The medical records of 92 patients who had undergone surgery after a diagnosis of CSH between April 1, 2015 and July 1, 2021 were reviewed retrospectively. Preoperative and postoperative computed tomography (CT) scans were reviewed, and the thickness of the hematoma and midline shift and the diameters of 2 burr holes opened were measured and recorded. The correlation between the burr hole diameter width and CSH thickness on postoperative CT scans and the improvement in midline shift were investigated statistically.

RESULTS

When the CT scans performed on the first postoperative day and first postoperative month were examined, we found that the preoperative hematoma thickness and midline shift were significantly reduced postoperatively (P < 0.001). A positive significant correlation was found between the improvement in the midline shift, posterior burr hole diameter, and anteroposterior burr hole arithmetic mean (P < 0.001 and P = 0.029, respectively).

CONCLUSIONS

Having examined the current surgical techniques in the treatment of CSH, we found that an increase in the burr hole craniostomy width, especially the posterior burr hole craniostomy width, contributed to the improvement in the midline shift.

Recurrent Subdural Hematoma: An Institutional Experience

Background Chronic subdural hematoma (CSDH) is a common neurosurgical problem, which offers a good outcome following surgery. In many cases, burr hole irrigation and drainage under local anesthesia can provide satisfactory results. However, recurrence can be a cause for concern for both the surgeon and the patient. While recurrence is not a frequent phenomenon, studies have reported rates of up to 31.6%. Aims and objectives In this study, our objective is to examine a comprehensive range of potential risk factors and provide valuable insights into identifying patients at a higher risk of recurrence to aid in surgical decision-making. Methodology This study employed a prospective and retrospective design, conducted between 2017 and 2021, at Sri Ramachandra Institute of Higher Education and Research. The study received ethical approval from the Institutional Ethics Committee. The research aimed to assess patients who underwent surgery for CSDH, with a particular focus on those who experienced recurrence. Results The average age of patients with recurrence was 71.5 years compared to 65.2 years in the no-recurrence group, but this difference did not show a significant statistical correlation. A significant male predominance was observed, with 27 men and four women affected (out of a total of 147 men and 73 women in the study), resulting in a statistically significant p-value of 0.01. On multivariate analysis, heterogenous subtypes were a significant predictor of recurrence (OR: 8.88, 95% CI: 6.96-16.54, p = 0.01). The mean midline shift in those with recurrence was 11.4 mm compared to 7.09 mm in those without recurrence. This was a statistically significant correlation with a p-value of 0.02. Regarding those with recurrence, 24 patients underwent evacuation using two burr holes, with one placed in the frontal region and another in the parietal region. All of these patients had a subdural drain placed, which was removed on postoperative day 2. The remaining eight patients underwent a mini-craniotomy for evacuation. We had four cases of refractory CSDH, all of whom underwent the second evacuation using burr holes. Three of them underwent evacuation via craniotomy, while the family of the fourth patient did not give consent for the procedure. Conclusion Patient-related factors such as gender, bilateral presentation, and the presence of hypertension and radiological factors such as the presence of heterogenous subtype and a significant midline shift are clues toward a higher chance of recurrence.

Surgical techniques for evacuation of chronic subdural hematoma: a mini-review

Chronic subdural hematoma is one of the most common neurosurgical pathologies with over 160,000 cases in the United States and Europe each year. The current standard of care involves surgically evacuating the hematoma through a cranial opening, however, varied patient risk profiles, a significant recurrence rate, and increasing financial burden have sparked innovation in the field. This mini-review provides a brief overview of currently used evacuation techniques, including emerging adjuncts such as endoscopic assistance and middle meningeal artery embolization. This review synthesizes the body of available evidence on efficacy and risk profiles for each critical aspect of surgical technique in cSDH evacuation and provides insight into trends in the field and promising new technologies.

Middle Meningeal Artery Embolization Versus Conventional Management for Patients With Chronic Subdural Hematoma: A Systematic Review and Meta-Analysis

BACKGROUND

The results from studies that compare middle meningeal artery (MMA) embolization vs conventional management for patients with chronic subdural hematoma are varied.

OBJECTIVE

To conduct a systematic review and meta-analysis on studies that compared MMA embolization vs conventional management.

METHODS

Medline, PubMed, and Embase databases were searched. Primary outcomes were treatment failure and surgical rescue; secondary outcomes were complications, follow-up modified Rankin scale > 2, mortality, complete hematoma resolution, and length of hospital stay (day). The certainty of the evidence was determined using the GRADE approach.

RESULTS

Nine studies yielding 1523 patients were enrolled, of which 337 (22.2%) and 1186 (77.8%) patients received MMA embolization and conventional management, respectively. MMA embolization was superior to conventional management for treatment failure (relative risk [RR] = 0.34 [0.14-0.82], P = .02), surgical rescue (RR = 0.33 [0.14-0.77], P = .01), and complete hematoma resolution (RR = 2.01 [1.10-3.68], P = .02). There was no difference between the 2 groups for complications (RR = 0.93 [0.63-1.37], P = .72), follow-up modified Rankin scale >2 (RR = 0.78 [0.449-1.25], P = .31), mortality (RR = 1.05 [0.51-2.14], P = .89), and length of hospital stay (mean difference = -0.57 [-2.55, 1.41], P = .57). For MMA embolization, the number needed to treat for treatment failure, surgical rescue, and complete hematoma resolution was 7, 9, and 3, respectively. The certainty of the evidence was moderate to high for primary outcomes and low to moderate for secondary outcomes.

CONCLUSION

MMA embolization decreases treatment failure and the need for surgical rescue without furthering the risk of morbidity and mortality. The authors recommend considering MMA embolization in the chronic subdural hematoma management.

Use of Novel Automated Active Irrigation With Drainage Versus Passive Drainage Alone for Chronic Subdural Hematoma-A Propensity Score-Matched Comparative Study With Volumetric Analysis

BACKGROUND

Passive drainage post-surgical evacuation of symptomatic chronic subdural hematoma (cSDH) is currently standard of care. High rates of infection, drain occlusion, and recurrence are associated complications.

OBJECTIVE

To explore the use of a novel double-lumen active automated irrigation and aspiration system, IRRAflow (IRRAS), for patients with cSDH and compared procedural and clinical outcomes against passive drainage alone with propensity score matching (PSM) and volumetric analysis.

METHODS

A prospectively maintained database was retrospectively searched for consecutive patients presenting with cSDH. One-to-one PSM of covariates (including baseline comorbidities and presentation hematoma volume) in active and passive irrigation groups was performed to adjust for treatment selection bias. Rates of hematoma clearance, catheter-related occlusion, and infection; number of revisions; and length of hospital stay were recorded.

RESULTS

This study included 55 patients: active continuous irrigation-drainage-21 (21 post-PSM) and passive drainage-34 (21 post-PSM). For PSM groups, a significantly higher rate of hematoma clearance was obtained in the active irrigation-drainage group (0.5 ± 0.4 vs 0.4 ± 0.5 mL/day) and in the passive drainage group; odds ratio (OR) = 1.291 (CI: 1.062-1.570, P = .002) and a significantly lower rate of catheter-related infections (OR = 0.051; CI: 0.004-0.697, P = .039). A nonsignificantly lower hematoma expansion rate at discharge was noted in the active irrigation-drainage group (4.8% vs 23.8%; OR = 0.127; P = .186). No statistical difference in all-cause in-hospital mortality or discharge Glasgow Coma Scale score was observed between groups.

CONCLUSION

Active and automated continuous irrigation plus drainage after cSDH surgical evacuation resulted in faster hematoma clearance and led to favorable clinical outcomes and low complication and revision rates compared with passive irrigation.

The efficacy of postoperative middle meningeal artery embolization on chronic subdural hematoma - A multicentered randomized controlled trial

Background

Middle meningeal artery (MMA) embolization has recently emerged as a potential treatment for chronic subdural hematoma (cSDH). Numerous retrospective studies have suggested that it can potentially reduce the risk of hematoma recurrence following surgical evacuation. We have conducted a randomized controlled trial to investigate the effectiveness of postoperative MMA embolization in reducing recurrence rate, residual hematoma thickness as well as improving functional outcome.

Methods

Patients aged 18 or above were recruited. Following evacuation through burr hole or craniotomy, patients were randomly allocated to undergo either MMA embolization or standard care (monitoring). The primary outcome was symptomatic recurrence requiring redo evacuation. Secondary outcomes include residual hematoma thickness and modified Rankin Scale (mRS) at 6 weeks and 3 months.

Results

Thirty-six patients (41 cSDHs) were recruited between April 2021 and September 2022. Seventeen patients (19 cSDHs) were allocated to the embolization group and 19 patients (22 cSDHs) were in the control group. No symptomatic recurrence was observed in the treatment group while 3 control patients (15.8%) underwent repeat surgery for symptomatic recurrence, however, it was not statistically significant (P = 0.234). Furthermore, there was no significant difference in residual hematoma thickness at 6 weeks or 3 months between the two groups. All patients in the embolization group had a good functional outcome (mRS 0-1) at 3 months, which was significantly higher than the 53% observed in the control group. No complications related to MMA embolization were reported.

Conclusion

Further study with larger sample size is required to evaluate the efficacy of MMA embolization.

Short-term follow-up pilot study of sole middle meningeal artery embolization for chronic subdural hematoma: influence of internal architecture on the radiological outcomes

PURPOSE

To identify prognostic factors with emphasis on chronic subdural hematoma (CSDH) architecture that determines short-term outcome of middle meningeal artery embolization (MMAE).

METHODS

Consecutive CSDH patients treated by MMAE (November 2019 and March 2022) were retrospectively analyzed. Four architectures were analyzed: homogeneous, laminar, separated, and trabecular types. Predictor variables from baseline CT were correlated with radiological endpoint (≥ 50% of hematoma volume reduction), time to reach the endpoint, and rate of volume reduction.

RESULTS

Study included 50 patients with 56 CSDHs (median age [first quartile, Q1; third quartile, Q3] 70.5 [60, 78.3] years; 36 were men). Separated type reached the endpoint at a lower rate on both bivariate (p = 0.02) and multivariate Cox model (0.034). Kaplan-Meier curves demonstrated that the median [Q1, Q3] time for 50% of the hematomas to reach the endpoint was 5 [4, 8], 4 [3, 5], 15 [15, 15], and 11 [4, 19] weeks for homogeneous, laminar, separated, and trabecular types, respectively. Linear mixed-effect model demonstrated a significant variation in the slope of hematoma volume reduction that was - 4.16 (95% confidence interval [CI] - 5.4, - 2.9), - 6.7 (95% CI - 8.35, - 5.1), - 2.03 (95% CI - 4.14, 0.08), and - 5.06 (95% CI - 6.8, - 3.32) ml per week for homogeneous, laminar, separated, and trabecular subtypes, respectively.

CONCLUSION

Separated CSDH is a poor prognostic type in achieving radiological endpoint and a slower rate of volume reduction. While, homogeneous and laminar types reached the endpoint faster than separated and trabecular types on short-term follow-up.

Efficacy analysis of neuroendoscopy-assisted burr-hole evacuation for chronic subdural hematoma: a systematic review and meta-analysis

The purpose of this study was to compare neuroendoscopy-assisted burr-hole evacuation with conventional burr-hole evacuation in the treatment of chronic subdural hematoma (CSDH), and to evaluate the curative effect of neuroendoscopy. This study follows PRISMA guidelines and uses the keywords "chronic subdural hematoma," "neuroendoscopies," "neuroendoscopy," "endoscopy," "endoscopic neurosurgery," and "neuroendoscopic surgery" to conduct an electronic search of online databases, including PubMed, Embase, Web of Science, and Cochrane Library. There were no restrictions on language or publication year. This meta-analysis involved 948 patients in six studies. The results showed that the recurrence rate in the neuroendoscopy group was significantly lower than that in the conventional burr-hole group (3.1% vs. 13.8%, P<0.001). Compared with the control group, the neuroendoscopy group had a longer operation time (P<0.001) and a shorter postoperative drainage time (P<0.001). In addition, there was no significant difference in hospital stay (P=0.14), mortality (P=0.39), postoperative morbidity (P=0.12), or 6-month neurological outcomes (P=0.32) between the two groups. It should be noted that the comparison of neurological outcomes was based on 269 patients (6/106 vs. 14/163). Compared with conventional burr-hole evacuation, neuroendoscopy-assisted burr-hole evacuation reduces the recurrence rate of CSDH and shortens the postoperative drainage time. However, the neuroendoscopy group did not have lower mortality or morbidity or better functional outcomes. In the future, randomized controlled trials are needed to further evaluate the efficacy and safety of neuroendoscopic surgery.

Middle Meningeal Artery Embolization in the Management of Chronic Subdural Hematoma: a Comprehensive Review of Current Literature

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.

Pilot Biomarker Analysis and Decision Tree Algorithm Modeling of Patients with Chronic Subdural Hematomas

The elderly population are at high risk for developing chronic subdural hematoma (cSDH). Surgical evacuation of cSDH is one of the most common procedures performed in neurosurgery. The present study aims to identify potential inflammatory biomarkers associated with its development and recurrence. Patients (>65 years of age) who presented with symptomatic cSDH (≥1 cm thickness or ≥5 mm midline shift [MLS]), requiring surgical intervention, were prospectively enrolled. The collected cSDH fluid was analyzed for inflammatory markers. Computed tomography (CT) scan data included pre-operative cSDH thickness and MLS. Outcome data included Glasgow Outcome Scale-Extended (GOS-E) score at 3, 6, and 12 months post-surgery, as well as cSDH recurrence. A decision tree model was used to determine the predictive power of extracted analytes for MLS, cSDH thickness, and recurrence. This pilot study includes 20 enrolled patients (mean age 77.9 ± 7.4 years and 85% falls). Rate of cSDH recurrence was 42%, with 21% requiring reoperation. Chemokine (C-X-C motif) ligand 9 (CXCL9) concentrations correlated with cSDH thickness (r = 0.975, p = 0.040). Interleukin (IL)-6 and vascular endothelial growth factor (VEGF)-A concentrations correlated with MLS (r = 0.974, p = 0.005; r = 0.472, p = 0.036, respectively). IL-5 concentrations correlated with more favorable GOS-E scores at 3, 6, and 12 months (r = 0.639, p = 0.006; r = 0.727, p = 0.003; r = 0.693, p = 0.026, respectively). Regulated on activation, normal T-cell expressed and secreted (RANTES) concentrations correlated with complete cSDH resolution (r = 0.514, p = 0.021). The decision tree model identified that higher concentrations of CXCL9 were predictive of MLS (risk ratio [RR] = 12.0), higher concentrations of IL-5 were predictive of cSDH thickness (RR = 4.5), and lower concentrations of RANTES were predictive of cSDH recurrence (RR = 2.2). CXCL9, IL-6, VEGF, IL-5, and RANTES are associated with recurrence after surgery and may be potential biomarkers for predicting cSDH recurrence and neurological outcomes.

Exhaustive drainage versus fixed-time drainage for chronic subdural hematoma after one-burr hole craniostomy (ECHO): study protocol for a multicenter randomized controlled trial

BACKGROUND

Chronic subdural hematomas (CSDHs) are one of the most common neurosurgical conditions. The standard surgical technique includes burr-hole craniostomy, followed by intraoperative irrigation and placement of subdural closed-system drainage. The drainage is generally removed after 48 h, which can be described as fixed-time drainage strategy. According to literature, the recurrence rate is 5-33% with this strategy. In our retrospective study, postoperative hematoma volume was found to significantly increase the risk of recurrence. Based on these results, an exhaustive drainage strategy is conducted to minimize postoperative hematoma volume and achieve a low recurrence rate and good outcomes.

METHODS

This is a prospective, multicenter, open-label, blinded endpoint randomized controlled trial designed to include 304 participants over the age of 18-90 years presenting with a symptomatic CSDH verified on cranial computed tomography or magnetic resonance imaging. Participants will be randomly allocated to perform exhaustive drainage (treatment group) or fixed-time drainage (control group) after a one-burr hole craniostomy. The primary endpoint will be recurrence indicating a reoperation within 6 months.

DISCUSSION

This study will validate the effect and safety of exhaustive drainage after one-burr hole craniostomy in reducing recurrence rates and provide critical information to improve CSDH surgical management.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT04573387. Registered on October 5, 2020.

Development and validation of a recurrent prediction model for patients with unilateral chronic subdural hematoma without hematoma volumetric analysis

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.

Butterfly needle tap and suction (BTS) technique: a treatment for recurrent chronic subdural hematoma after burr hole craniostomy

BACKGROUND

In this study, we propose a butterfly needle tap and suction (BTS) technique for recurrent chronic subdural hematoma (CSDH) as an alternative to reoperation with burr hole craniostomy (BHC) and investigate its efficacy and safety. The procedure involves percutaneous puncture through the burr hole created during the previous surgery and subsequent hematoma evacuation using a butterfly needle.

METHODS

This retrospective study included patients who underwent BTS for CSDH at Ogaki Municipal Hospital between January 2017 and December 2020. The follow-up CT scans were reviewed after several weeks. We evaluated the number of percutaneous punctures required to resolve CSDH during the BTS technique, the volume of the evacuated hematoma, and procedure-related complications.

RESULTS

Twenty-six patients were enrolled in the study, 21 of whom achieved resolution of the hematoma using punctures with the BTS technique alone (mean, 2.2 ± 1.5). Five patients had a recurrence of hematoma after one or more punctures during the BTS technique, and they underwent reoperation with BHC according to the surgeon's decision or patient requests. Among the 55 punctures, 43.0 ± 16.0 ml of hematoma was evacuated per puncture. The evacuated hematoma volume was 41.9 ± 16.4 ml in the BTS-alone group and 49.4 ± 12.9 ml in the reoperation group, with no significant difference (p = 0.25). Three patients complained of a headache during the puncture procedure, and no other complications, including intracranial hemorrhage or infection, were reported therein.

CONCLUSIONS

The BTS technique is an effective alternative to reoperation with BHC.

Single Frontal Burr-Hole Craniostomy Under Local Anesthesia for Treating Chronic Subdural Hematoma in the Septuagenarians and Older Adults: Surgical Technique and Results

Background Chronic subdural hematoma (CSDH) is not a totally benign disease in the elderly patients, especially those aged 70 years and above. Hence, the surgical treatment of CSDH in aged patients needs to be as minimally disruptive as possible.

Methods An annotated description of the surgical technique of single frontal burr-hole craniostomy performed under local anesthesia and without closed tube drainage for evacuating CSDH in the septuagenarians and older adults is given. We also review the outcome of the procedure on a prospective consecutive cohort of patients in our service

Results Thirty patients, 25 males, aged 70 years and above successfully underwent this surgical procedure. Their mean age was 76.5 years (standard deviation, 4.3). The CSDH was bilateral in 30% (9/30), and more left sided in the rest, the unilateral cases, and was of mixed density radiologically, in most cases (73%, 22/30). Clinical presentation was mainly gait impairment, cognitive decline, and headache, and 57% (17/30) presented with coma or stupor as assessed by the Markwalder grading scale.

The surgery was successfully executed in all, median duration 45.0 minutes (interquartile range 37.3–60.0), and solely under local anesthesia in 77% (23/30) or with momentary short-acting sedation in the rest. The outcome was very good in 90.0% (27/30) using the modified Rankin Scale (mRS) including two-third (20/30) completely asymptomatic (mRS 0) and 7/30 with only slight symptoms/disability, mRS ≤ 2. Three patients died perioperatively, all presenting in coma.

Conclusion This surgical technique appears very effectual for CSDH, is executed at a comparatively low cost, and, being much less disruptive than other traditional methods, may be a more homeostatic operative treatment in geriatric patients at least.

Surgical treatment for chronic subdural hematoma in the elderly: A retrospective analysis

Background

Chronic subdural hematoma (CSDH) is primarily a disease of the elderly. Less invasive interventions are often offered for elderly (> 80 years) patients due to concerns for elevated surgical risk, although data suggesting a clear outcome benefit is lacking.

Methods

All patients aged 65 years or older who underwent surgical treatment for CSDH at a single institution over a 4-year period were evaluated in this retrospective analysis. Surgical options included twist drill craniostomy (TDC), burr hole craniotomy (BHC), or standard craniotomy (SC). Outcomes, demographics, and clinical data were collected. Practice patterns and outcomes for patients older than 80 years old were compared to the age 65-80 cohort.

Results

110 patients received TDC, 35 received BHC, and 54 received SC. There was no significant difference in post-operative complications, outcomes, or late recurrence (30-90 days). Recurrence at 30 days was significantly higher for TDC (37.3% vs. 2.9% vs 16.7%, p 80 group, SC had higher risk of stroke and increased length of stay.

Conclusion

Twist drill craniostomy, burr hole craniostomy, and standard craniotomy have similar neurologic outcomes in elderly patients. Presence of thick membranes is a relative contra-indication for TDC due to high 30-day recurrence. Patients > 80 have higher risk of stroke and increased length of stay with SC.

Clinical Outcome and Recurrence Risk of Chronic Subdural Hematoma After Surgical Drainage

Introduction Chronic subdural hematoma (CSDH) is one of the most encountered neurosurgical cases. CSDH is defined as the accumulation of liquified blood products in the space between the dura and the arachnoid. A reported incidence of 17.6/100,000/year has more than doubled in the past 25 years in parallel with an aging population. Surgical drainage remains the mainstay of treatment, yet it is challenged by variable recurrence risks. Less invasive embolization methods of the middle meningeal artery (EMMA) could reduce the recurrence risks. Before adopting a newer treatment (EMMA), it is prudent to establish the outcomes from surgical drainage. The purpose of this study is to assess the clinical outcome and recurrence risk in surgically treated CSDH patients in our center. Methods A retrospective search of our surgical database was done to identify CSDH patients undergoing surgical drainage in the year 2019-2020. Demographic and clinical details were collected, and quantitative statistical analysis was performed. Peri-procedural radiographic information and follow-ups were also included as per the standard of care. Results A total of 102 patients (mean age: 69 years; range: 21-100 years; male: 79) with CSDH underwent surgical drainage with repeat surgery in 13.7% of the patients (n=14). Peri-procedural mortality and morbidity were 11.8%(n=12) and 19.6% (n=20), respectively. Overall, among our patient population, recurrence was seen in 22.55% (n=23). The mean total hospital stay was 10.6 days. Conclusions Our retrospective cohort study showed an institutional CSDH recurrence risk of 22.55%, in keeping with what is reported in the literature. This baseline information is important for a Canadian setting and provides a basis for comparison for future Canadian trials.

Change in Hematoma Size after Dexamethasone Therapy in Chronic Subdural Hematoma Subtypes: A Prospective Study in Symptomatic Patients

The main treatment strategy for chronic subdural hematoma is surgical intervention. When a conservative pharmacological approach is considered in symptomatic patients, mainly dexamethasone therapy is applied. Recent trials revealed dexamethasone therapy to be an ineffective treatment in symptomatic patients with chronic subdural hematoma. Whether the efficacy of dexamethasone therapy differs in radiological hematoma subtypes is unknown. The aim of this substudy was to identify which hematoma subtype might be favorable for dexamethasone therapy. As part of a randomized controlled trial, symptomatic chronic subdural hematoma patients received 19-days dexamethasone therapy. The primary outcome measure was the change in hematoma size as measured on follow-up computed tomography (CT) after 2 weeks of dexamethasone in six hematoma (architectural and density) subtypes: homogeneous total, laminar, separated and trabecular architecture types, and hematoma without hyperdense components (homogeneous hypodense, isodense) and with hyperdense components (homogeneous hyperdense, mixed density). We analyzed hematoma thickness, midline shift, and volume using multi-variable linear regression adjusting for age, sex and baseline value of the specific radiological parameter. From September 2016 until February 2021, 85 patients were included with a total of 114 chronic subdural hematoma. The mean age was 76 years and 25% were women. Larger decrease in hematoma thickness and midline shift was revealed in hematoma without hyperdense components compared with hematoma with hyperdense components (adjusted [adj.] b -2.2 mm, 95% confidence interval [CI] -4.1 to -0.3 and adj. b -1.3 mm, 95% CI -2.7 to 0.0 respectively). Additional surgery was performed in 57% of patients with the highest observed rate (81%) in separated hematoma. Largest hematoma reduction and better clinical improvement was observed in chronic subdural hematoma without hyperdense components after dexamethasone therapy. Evaluation of these parameters can be part of an individualized treatment strategy.