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Gharaibeh S, Shurman A, Gharaibeh A, Torcuator R. A Case Report of Tranexamic Acid for the Treatment of Chronic Subdural Hematoma in an 86-Year-Old Patient. Cureus 2024; 16:e66846. [PMID: 39144412 PMCID: PMC11323430 DOI: 10.7759/cureus.66846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2024] [Indexed: 08/16/2024] Open
Abstract
Fibrinolytic and coagulative hyperactivity is proven to have a role in liquefaction and progression of chronic subdural hematoma (CSDH). Tranexamic acid was one of the pharmaceutical options that was explored, as it inhibits the hyper-fibrinolytic activity and reduces the vascular permeability in CSDH, leading to a gradual resolution of the hematoma. In this case study, we present a case of using tranexamic acid for CSDH treatment in an 86-year-old patient with co-morbidities. The complete resolution of the hematoma following using tranexamic acid in this case with no history of recurrence in two years follow-up supports its efficacy in CSDH treatment and may be considered as one of the strategies that help prevent surgeries.
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Affiliation(s)
- Shatha Gharaibeh
- Center for Cognition and Neuroethics, University of Michigan-Flint, Flint, USA
- Clinical Research, Insight Research Institute, Flint, USA
| | - Abdallah Shurman
- Center for Cognition and Neuroethics, University of Michigan-Flint, Flint, USA
- Clinical Research, Insight Research Institute, Flint, USA
| | - Abeer Gharaibeh
- Clinical Research, Insight Institute of Neurosurgery and Neuroscience, Flint, USA
- Clinical Research, Insight Research Institute, Flint, USA
| | - Roy Torcuator
- Neurosurgery, Insight Institute of Neurosurgery and Neuroscience, Flint, USA
- Neurosurgery, Insight Surgical Hospital, Warren, USA
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2
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Scruton TJ. Updates on the diagnosis and management of subdural hematoma. JAAPA 2024; 37:9-15. [PMID: 38980290 DOI: 10.1097/01.jaa.0000000000000055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Abstract
ABSTRACT Intracranial hemorrhage is a potentially life-threatening condition categorized into four main groups by the location of bleeding: epidural, subdural, subarachnoid, and intraparenchymal. Subdural hematoma (SDH) is increasingly common as the population of older adults increases. Clinicians must recognize the typical presentations and order diagnostic imaging studies to make a timely diagnosis and referral to neurosurgery for definitive treatment. Understanding the pathophysiology and risk factors for chronic or expanding SDH informs decision-making in managing anticoagulants. Emerging treatments offer potential alternatives to the traditional evacuation of SDH by craniotomy, which remains the standard of care for most symptomatic patients.
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Affiliation(s)
- Thomas J Scruton
- Thomas J. Scruton has been a PA for more than 20 years, practicing primarily in neurological surgery. The author has disclosed no potential conflicts of interest, financial or otherwise
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3
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Chen H, Colasurdo M, Malhotra A, Gandhi D, Bodanapally UK. Advances in chronic subdural hematoma and membrane imaging. Front Neurol 2024; 15:1366238. [PMID: 38725642 PMCID: PMC11079242 DOI: 10.3389/fneur.2024.1366238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 03/14/2024] [Indexed: 05/12/2024] Open
Abstract
Chronic subdural hematoma (cSDH) is projected to become the most common cranial neurosurgical disease by 2030. Despite medical and surgical management, recurrence rates remain high. Recently, middle meningeal artery embolization (MMAE) has emerged as a promising treatment; however, determinants of disease recurrence are not well understood, and developing novel radiographic biomarkers to assess hematomas and cSDH membranes remains an active area of research. In this narrative review, we summarize the current state-of-the-art for subdural hematoma and membrane imaging and discuss the potential role of MR and dual-energy CT imaging in predicting cSDH recurrence, surgical planning, and selecting patients for embolization treatment.
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Affiliation(s)
- Huanwen Chen
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States
- Department of Neurology, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Marco Colasurdo
- Department of Interventional Radiology, Oregon Health & Science University, Portland, OR, United States
| | - Ajay Malhotra
- Department of Radiology, Yale New Haven Hospital, New Haven, CT, United States
| | - Dheeraj Gandhi
- Department of Radiology, University of Maryland Medical Center, Baltimore, MD, United States
- Department of Neurology, University of Maryland Medical Center, Baltimore, MD, United States
- Department of Neurosurgery, University of Maryland Medical Center, Baltimore, MD, United States
| | - Uttam K. Bodanapally
- Department of Radiology, University of Maryland Medical Center, Baltimore, MD, United States
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Albalkhi I, Alaswad M, Saleh T, Senjab A, Helal B, Khan JA. Adjuvant Tranexamic Acid for Reducing Postoperative Recurrence of Chronic Subdural Hematoma in the Elderly: A Systematic Review and Meta-Analysis. World Neurosurg 2024; 182:e829-e836. [PMID: 38101544 DOI: 10.1016/j.wneu.2023.12.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 12/09/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND Chronic subdural hematoma (CSDH) is a frequently encountered neurosurgical disease among the elderly. The mainstay treatment involves surgical evacuation, but recurrence rates of approximately 13% pose complications. Adjuvant treatments, including tranexamic acid (TXA), have been explored, yet consensus on their efficacy and safety in elderly patients remains uncertain. The study aims to examine the role of TXA as adjunctive therapy in reducing CSDH recurrence and explore any potential association between TXA use and thrombotic events in this patient population. METHODS The systematic review and meta-analysis adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and Cochrane Handbook standards, searching databases up to July 2023 for randomized controlled trials and propensity-matched cohorts evaluating adjuvant TXA. The primary outcome was CSDH recurrence, and the secondary outcome was thrombosis risk, measured as relative risks. RESULTS A total of 6 studies were included, comprising 1403 patients with CSDH who underwent surgical treatment. Four studies were randomized controlled trials, while the other 2 were propensity-matched cohorts. The overall pooled relative risk for CSDH recurrence in the TXA group compared to the control group was 0.41 (95% confidence interval [0.29-0.59], P < 0.01), indicating a significant reduction in recurrence with TXA treatment. CONCLUSIONS In conclusion, our study indicates that adjuvant TXA may help reduce CSDH recurrence in elderly patients undergoing surgical treatment. However, the study has limitations and there is a need for further research to validate these findings.
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Affiliation(s)
- Ibrahem Albalkhi
- Department of Neuroscience, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia; Department of Neuroradiology, Great Ormond Street Hospital NHS Foundation Trust, London, United Kingdom.
| | - Marwan Alaswad
- Department of Neuroscience, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Tariq Saleh
- Department of Neuroscience, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Abdulrahaman Senjab
- Department of Neuroscience, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Baraa Helal
- Department of Neuroscience, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Jibran Ahmad Khan
- Department of Neuroscience, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
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Liu R, Li Y, Richard SA, Lan Z, Liu X. Rapid disappearance of acute subdural hematoma due to abrogated hyper-fibrinolytic activity by tranexamic acid: Case report. Medicine (Baltimore) 2023; 102:e35998. [PMID: 37960780 PMCID: PMC10637492 DOI: 10.1097/md.0000000000035998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 10/17/2023] [Indexed: 11/15/2023] Open
Abstract
RATIONALE Acute subdural hematoma (ASDH) occurs after tearing of bridging veins within the dura resulting in the accumulation of blood between the arachnoid and dura layers within 72 hours after traumatic head injury. Also, antigen fibrin D-dimer (DD) is the principal enzymatic degradation product of cross-linked fibrin by plasmin. We observed that early tranexamic acid (TXA) treatment resolved hyper-fibrinolysis and rapid disappearance ASDH. PATIENTS CONCERNS A 48-year-old female presented with unconsciousness for 2 hours after head trauma. Her Glasgow Coma Scale score was >8 points. DIAGNOSIS Computed tomography scan established ASDH with midline shift and brainstem compression and surgery was scheduled. Also, laboratory results indicated high DD spike of 34,820 μg/L and a reduction in plasma fibrinogen 1 hour after the injury. INTERVENTION She was treated with intravenous TXA immediately after admission. OUTCOMES Her DD spike decreased remarkably in 48 hours with associated rapid disappearance of ASDH thereby averting surgical intervention. She recovered fully with no long-term complications. LESSONS Historically, hyper-fibrinolysis is associated with poor outcome in head trauma. However, early initiation of TXA which is noninvasive treatment modality for ASDH could avert surgery and reduce cost, anesthesia, and other complications associated with surgery.
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Affiliation(s)
- Rong Liu
- Department of Neurosurgery, West China Hospital, Sichuan University, Sichuan, China
| | - Yan Li
- Department of Intensive Care Unit, Luojiang People’s Hospital, Sichuan, China
| | - Seidu A. Richard
- Department of Neurosurgery, West China Hospital, Sichuan University, Sichuan, China
- Institute of Neuroscience, Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhigang Lan
- Department of Neurosurgery, West China Hospital, Sichuan University, Sichuan, China
| | - Xuesong Liu
- Department of Neurosurgery, West China Hospital, Sichuan University, Sichuan, China
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Langlois AM, Touchette CJ, Mathieu D, Iorio-Morin C. Classification of subdural hematomas: proposal for a new system improving the ICD Coding Tools. Front Neurol 2023; 14:1244006. [PMID: 37885484 PMCID: PMC10598644 DOI: 10.3389/fneur.2023.1244006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 09/28/2023] [Indexed: 10/28/2023] Open
Abstract
Background The International Statistical Classification of Diseases (ICD) classifies subdural hematoma (SDH) as traumatic or non-traumatic. In clinical settings, however, SDH is typically described as either acute or chronic. Objective The goal of this study was to assess how the ICD Coding Tools captures the clinical terminology and propose an improved classification that would increase the system's usefulness in administrative, statistical and research applications. Methods We performed a retrospective analysis of patients who presented to our center with an ICD diagnostic code for either traumatic or non-traumatic SDH. A qualitative analysis of patients' charts was performed to identify elements relevant to management and prognosis, following which a meeting between expert investigators was held to elaborate a new classification of SDH. Imaging from all patients was then reviewed and cases were reclassified according to our proposed system. Results A total of 277 SDH cases were included. Themes documented in the charts included chronicity, etiology, side, and symptoms. We created a new classification which distinguishes acute SDH (aSDH) from membrane-associated SDH (mSDH). aSDH were further divided into traumatic aSDH (taSDH) and non-traumatic aSDH (ntaSDH), while mSDH were divided into acute on chronic (a/cSDH), subacute (sSDH) and chronic (cSDH) categories. Conclusion The ICD coding system correctly identifies taSDH and ntaSDH. However, it remains non-specific for mSDH. We propose this new SDH classification system to better capture chronicity and etiology - factors felt to impact management and prognosis.
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Affiliation(s)
| | | | | | - Christian Iorio-Morin
- Division of Neurosurgery, Department of Surgery, Université de Sherbrooke, Sherbrooke, QC, Canada
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Wu M, Wajeeh H, McPhail MN, Seyam O, Flora J, Nguyen H. Usage of Tranexamic Acid for Treatment of Subdural Hematomas. Cureus 2023; 15:e37628. [PMID: 37200656 PMCID: PMC10185923 DOI: 10.7759/cureus.37628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 04/15/2023] [Indexed: 05/20/2023] Open
Abstract
The collection of blood in the subdural layer within the cranium is classified as a subdural hematoma. Prevalence of subdural hematomas is most common among older populations with the current standard of treatment being invasive surgical evacuation for patients presenting with acute subdural hematomas with a midline shift greater than 5 mm on computed tomography (CT).Tranexamic acid (TXA) has been identified as an alternative, non-invasive option to treat patients presenting with subdural hematoma who are not suitable for surgical intervention. The presenting case involves a 90-year-old female who arrived with a code stroke with the chief complaint of right lower extremity weakness. A stroke series CT panel revealed a left frontal multiloculated subdural hematoma, measuring 130 mL with mass effect and a midline shift of 7 mm. The patient was recommended a craniotomy for hematoma evacuation or access to hospice for comfort care. A second opinion resulted in the administration of TXA. After the full completion of a TXA course, the patient achieved baseline mobility. The final measurements revealed a final hematoma volume of 10 mL and a midline shift of less than 2 mm. Current literature, as well as the case described, has begun demonstrating the efficacy of the usage of TXA in the reabsorption of subdural hematomas and should encourage further exploration into society guidelines for the usage of TXA as a non-invasive alternative to treat subdural hematomas.
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Affiliation(s)
- Michael Wu
- Osteopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
| | - Hassaan Wajeeh
- Osteopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
| | - Marissa N McPhail
- Osteopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
| | - Omar Seyam
- Osteopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
| | - Jamie Flora
- Osteopathic Medicine, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Fort Lauderdale, USA
| | - Hoang Nguyen
- Basic Sciences, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Clearwater, USA
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Msheik A, Fares Y, Mohanna M, Aoude A, Shkeir M, Chehade F, Kanj A, Mohanna A. Middle meningeal artery embolisation: The review of a new treatment for chronic subdural hematomas. Surg Neurol Int 2023; 14:66. [PMID: 36895214 PMCID: PMC9990792 DOI: 10.25259/sni_1096_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 02/03/2023] [Indexed: 02/26/2023] Open
Abstract
Background This is a literature review aiming to provide an update about the recent findings related to the efficacy of middle meningeal artery embolization (MMAE) in the treatment of chronic subdural hematomas (cSDHs), comparison with conventional therapy and deduction of the current recommendations and indications. Methods The literature is reviewed using a search through the PubMed index using keywords. Studies are then screened, skimmed, and thoroughly read. 32 studies fulfilled the inclusion criteria and are included in the study. Results Five indications for the application of MMA embolization (MMAE) are deducted from the literature. The usage as a preventive measure after surgical treatment of symptomatic cSDHs in patients with a high risk of recurrence and the usage as a standalone procedure has been the most common reasons for indication of this procedure. Rates of failures for the aforementioned indications have been 6.8% and 3.8%, respectively. Conclusion The safety of MMAE as a procedure is regarded as a general theme in the literature and can be considered for future applications. Usage of this procedure in clinical trials with more patient segregation and timeframe assessment relative to surgical intervention are recommendations of this literature review.
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Affiliation(s)
- Ali Msheik
- Department of Neurological Surgery, Lebanese University, Faculty of Medical Sciences
| | - Youssef Fares
- Department of Neurological Surgery, Neuroscience Research Center, Faculty of Medical Sciences, Lebanese University, Lebanon
| | - Mohammad Mohanna
- Department of Oncology, Cleveland Clinic, Weston, Florida, United States
| | - Ahmad Aoude
- Department of Neurological Surgery, Al Rassoul Al-Azam Hospital
| | - Mohamad Shkeir
- Head of Radiology Department, Zahraa Hospital University Medical Center
| | - Feras Chehade
- Department of Nuclear Medicine Radiobiology Radiopathology, Faculty of Medical Sciences, Lebanese University
| | - Ali Kanj
- Radiology Department, Bahman Hospital, Faculty of Medicine, Lebanese University
| | - Assaad Mohanna
- Head of Department of Radiology, Faculty of Medicine, Lebanese University, Bahman Hospital, Centre Hospitalier Vallee de la Maurienne-France, Beirut, Lebanon
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Hatfield JK, Komisarow JM. Commentary: Randomized Trial Comparing Burr Hole Craniostomy, Minicraniotomy, and Twist Drill Craniostomy for Treatment of Chronic Subdural Hematoma. Neurosurgery 2022; 91:e100-e101. [DOI: 10.1227/neu.0000000000002076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 05/25/2022] [Indexed: 11/19/2022] Open
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10
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Weigel R, Schilling L, Krauss JK. The pathophysiology of chronic subdural hematoma revisited: emphasis on aging processes as key factor. GeroScience 2022; 44:1353-1371. [DOI: 10.1007/s11357-022-00570-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 04/07/2022] [Indexed: 12/24/2022] Open
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Immenga S, Lodewijkx R, Roos YBWEM, Middeldorp S, Majoie CBLM, Willems HC, Vandertop WP, Verbaan D. Tranexamic acid to prevent operation in chronic subdural haematoma (TORCH): study protocol for a randomised placebo-controlled clinical trial. Trials 2022; 23:56. [PMID: 35042560 PMCID: PMC8767703 DOI: 10.1186/s13063-021-05907-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 12/03/2021] [Indexed: 11/16/2022] Open
Abstract
Background Chronic subdural haematoma (cSDH) occurs mainly in the elderly. Surgical evacuation is effective, but in these old, often frail, patients with multi-comorbidity, surgery carries significant risks for future cognitive functioning and loss of independency. Therefore, a growing interest is noted for a non-surgical treatment with medication such as tranexamic acid (TXA). In five small retrospective series, this antifibrinolytic drug showed a beneficial effect on the spontaneous resolution of the haematoma, and with that, the necessity for surgery. Methods For this randomised, placebo-controlled clinical multicentre trial, all cSDH patients, over 50 years old with mild symptoms (Glasgow Coma Score (GCS) ≥ 14, modified National Institutes of Health Stroke Scale (mNIHSS) ≤ 4), a midline shift of ≤ 10 mm and in whom a primary conservative treatment is chosen, are eligible for study participation. After informed consent, 140 patients will be randomised to receive either TXA 500 mg or placebo two times daily for 28 days. The primary outcome is the necessity for surgery within 12 weeks; secondary outcomes are cSDH volume, neurological impairment (mNIHSS), falling incidents, cognitive functioning (Montreal Cognitive Assessment (MOCA)), performance in activities of daily living (Barthel and Lawton score), functional outcome (modified Rankin Scale (mRS)), quality of life (Short Form Health Survey (SF-36) and EuroQol 5-Dimension Health Survey (EQ-5D)), mortality and the use of care and health-related costs (Medical Consumption Questionnaire (iMCQ) and Productivity Cost Questionnaire (iPCQ)) at 12 weeks and 6 months. Discussion This phase III trial investigating the efficacy of TXA to prevent surgery for cSDH is the first in including patients using anticoagulants and mentally incompetent patients, since these comprise a significant part of the target population. Also, this study is one of the first to prospectively measure functional outcome and quality of life in cSDH patients. Final results of this study are expected in 2024. Trial registration Dutch Trial Registry (Nederlands Trial Register) NL6584. Registered on 11 November 2017 ClinicalTrials.govNCT03582293. Registered on 11 July 2018 EU Clinical Trials Register 2017-004311-40. Registered on 29 March 2018
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Affiliation(s)
- S Immenga
- Department of Neurosurgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
| | - R Lodewijkx
- Department of Neurosurgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Y B W E M Roos
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - S Middeldorp
- Department of Vascular Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - C B L M Majoie
- Department of Radiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - H C Willems
- Department of Internal Medicine, Geriatrics Section, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - W P Vandertop
- Department of Neurosurgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - D Verbaan
- Department of Neurosurgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Zhang J. Expert consensus on drug treatment of chronic subdural hematoma. Chin Neurosurg J 2021; 7:47. [PMID: 34809712 PMCID: PMC8607705 DOI: 10.1186/s41016-021-00263-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 09/22/2021] [Indexed: 11/10/2022] Open
Abstract
Chronic subdural hematoma (CSDH) is a chronic space-occupying lesion formed by blood accumulation between arachnoid and dura mater, which is usually formed in the third week after traumatic brain injury. Surgical treatment is usually the first choice for patients with CSDH having a significant space-occupying effect. Most of the patients showed good results of surgical treatment, but still some patients had a postoperative recurrence (the recurrence rate was up to 33%). Because CSDH is often seen in the elderly, patients are weak and have many basic diseases. The risk of surgical treatment is high; serious complications and even death (the death rate is up to 32%) can often occur. The overall good prognosis rate of patients aged more than 90 years is 24%. The drug treatment can provide a safe and effective treatment for elderly patients who are weak, intolerable to surgery, or failed in surgery. Low-dose and long-term use of atorvastatin (20mg/d) is suggested for continuous treatment for at least 8 weeks, while low-dose and short-term use of dexamethasone can improve the therapeutic effect of atorvastatin on CSDH. Patients should undergo CT or MRI scanning at least one time within 2 weeks after the start of drug treatment.
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Affiliation(s)
- Jianning Zhang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, 300052, China. .,Key Laboratory of Post-trauma Neuro-repair and Regeneration in Central Nervous System, Ministry of Education, Tianjin, 300052, China. .,Tianjin Key Laboratory of Injuries, Variations and Regeneration of Nervous System, Tianjin, 300052, China. .,Tianjin Neurological Institute, Tianjin, 300052, China.
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Tamura R, Sato M, Yoshida K, Toda M. History and current progress of chronic subdural hematoma. J Neurol Sci 2021; 429:118066. [PMID: 34488045 DOI: 10.1016/j.jns.2021.118066] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Revised: 08/25/2021] [Accepted: 08/31/2021] [Indexed: 11/18/2022]
Abstract
Chronic subdural hematoma (CSDH) is characterized by an encapsulated collection of old blood. Although CSDH has become the most frequent pathologic entity in daily neurosurgical practice, there are some unresolved research questions. In particular, the causes and recurrent risk factors of CSDH remain as an object of debate. The split of the dural border layer forms a few tiers of dural border cells over the arachnoid layer. Tissue plasminogen activator plays an important role as a key factor of defective coagulation. Historically, CSDH has often been treated via burr hole craniostomy using a closed drainage system. Several different operative strategies and peri-operative strategies such as the addition of burr holes, addition of cavity irrigation, position of drain, or postural position, have been described previously. Although the direction of the drainage tube, residual air, low intensity of T1-weighted images on MRI, and niveau formation have been reported as risk factors for recurrence, antiplatelet or anticoagulant drug use has not yet been verified as a risk factor. Recently, pharmaceutical strategies, including atorvastatin, significantly improved the neurological function in CSDH patients. Many case series, without randomization, have been reported; and given its promising result, several randomized clinical trials using pharmaceutical as well as operative and perioperative strategies were initiated to obtain sufficient data. In contrast, relatively fewer basic studies have achieved clinical applications in CSDH, although it is one of the most common clinical entities. Further scientific basic research may be essential for achieving a novel treatment strategy for CSDH.
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Affiliation(s)
- Ryota Tamura
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan; Department of Neurosurgery, Kawasaki Municipal Hospital, Shinkawadori, Kawasaki-ku, Kanagawa 210-0013, Japan
| | - Mizuto Sato
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Kazunari Yoshida
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Masahiro Toda
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan.
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Lizana J, Aliaga N, Basurco A. Hematoma subdural crónico: Una patología común de manejo complejo. Surg Neurol Int 2021. [DOI: 10.25259/sni_676_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Antecedentes:
El hematoma subdural crónico (HSDC) es una patología ampliamente estudiada, muy frecuente, sobre todo en adultos mayores; su cuadro clínico tiene una apariencia benigna y suele ir acompañado de múltiples comorbilidades asociadas a la edad, lo que resulta en un aumento de las complicaciones e incluso la muerte. Con el incremento de la expectativa de vida a nivel mundial, el uso de medicamentos antitrombóticos es cada vez más frecuente. El papel de estos fármacos en la evolución de la enfermedad como en la recurrencia, sigue siendo motivo de discusión.
Métodos:
Los autores revisaron la fisiopatología y características clínicas del HSDC. El presente artículo discute acerca de las terapéuticas actuales y las nuevas opciones de tratamiento que podrían mejorar los resultados. Este manuscrito es susceptible de cambios en el tiempo, con el desarrollo científico y tecnológico.
Resultados:
El HSDC puede ser abordado por vía quirúrgica y farmacológica; no obstante, un manejo individualizado requiere la consideracion cuidadosa de diversos factores. A pesar de los avances en el campo de la neurocirugía, la clásica trepanación craneal sigue siendo el Gold estándar en el HSDC y sobre todo en pacientes con síntomas graves. Se debe resaltar que aún hay aspectos de este procedimiento (como la localización del dren, número de drenajes, el efecto de la irrigación, la temperatura de la solución con que se irriga, etc.) que siguen siendo materia de estudio.
Conclusiones:
Entender el mecanismo de la enfermedad ha permitido explicar su historia natural y a su vez proponer nuevas alternativas de tratamiento. El manejo médico (atorvastatina, corticoides) ha generado gran interés por sus alentadores resultados preliminares. Recientemente, se ha reportado la terapia endovascular como una alternativa segura y existe gran expectativa por confirmar su efecto en estudios más grandes.
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Affiliation(s)
- Jafeth Lizana
- Department of Neurosurgery, Hospital Nacional Guillermo Almenara, Lima, Peru,
| | - Nelida Aliaga
- Department of Medicine, School of Biomedical Sciences, Austral University, Mariano Acosta, Buenos Aires, Argentina
| | - Alfonso Basurco
- Department of Neurosurgery, Hospital Nacional Guillermo Almenara, Lima, Peru,
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15
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Holl DC, Chari A, Iorio-Morin C, Dammers R, van der Gaag NA, Kolias AG, Hutchinson PJ, Edlmann E. Study Protocol on Defining Core Outcomes and Data Elements in Chronic Subdural Haematoma. Neurosurgery 2021; 89:720-725. [PMID: 34318894 PMCID: PMC8440066 DOI: 10.1093/neuros/nyab268] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 05/09/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Core Outcome Sets (COSs) are necessary to standardize reporting in research studies. This is urgently required in the field of chronic subdural hematoma (CSDH), one of the most common disease entities managed in neurosurgery and the topic of several recent trials. To complement the development of a COS, a standardized definition and baseline Data Elements (DEs) to be collected in CSDH patients, would further improve study quality and comparability in this heterogeneous population. OBJECTIVE To, first, define a standardized COS for reporting in all future CSDH studies; and, second, to identify a unified CSDH Definition and set of DEs for reporting in future CSDH studies. METHODS The overall study design includes a Delphi survey process among 150 respondents from 2 main stakeholder groups: healthcare professionals or researchers (HCPRs) and Patients or carers. HCPR, patients and carers will all be invited to complete the survey on the COS, only the HCPR survey will include questions on definition and DE. EXPECTED OUTCOMES It is expected that the COS, definition, and DE will be developed through this Delphi survey and that these can be applied in future CSDH studies. This is necessary to help align future research studies on CSDH and to understand the effects of different treatments on patient function and recovery. DISCUSSION This Delphi survey should result in consensus on a COS and a standardized CSDH Definition and DEs to be used in future CSDH studies.
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Affiliation(s)
- Dana C Holl
- Department of Neurosurgery, Erasmus Medical Centre, Erasmus MC Stroke Centre, Rotterdam, the Netherlands
| | - Aswin Chari
- Developmental Neurosciences, Great Ormond Street Institute of Child Health, University College London, London, UK.,Department of Neurosurgery, Great Ormond Street Hospital, London, UK
| | | | - Ruben Dammers
- Department of Neurosurgery, Erasmus Medical Centre, Erasmus MC Stroke Centre, Rotterdam, the Netherlands
| | - Niels A van der Gaag
- University Neurosurgical Centre Holland (UNCH), Leiden University Medical Centre, Haaglanden Medical Centre, Haga Teaching Hospital, the Netherlands
| | - Angelos G Kolias
- Division of Neurosurgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
| | - Peter J Hutchinson
- Division of Neurosurgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
| | - Ellie Edlmann
- Department of Neurosurgery, South West Neurosurgical Centre, University Hospitals Plymouth NHS Trust, Plymouth, UK.,Faculty of Health, Peninsula Medical School, University of Plymouth, Plymouth, UK
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16
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Siddiq F, Bains NK, Herbert JP, Akhtar IN, Thomas AJ, Kan P, Cassarly C, Martin RH, Selim M, Qureshi AI. Reliability of an Automated Computerized Hematoma Volumetric Analysis Protocol in Patients with Chronic Subdural Hemorrhage. World Neurosurg 2021; 150:e372-e377. [PMID: 33722724 DOI: 10.1016/j.wneu.2021.03.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 03/02/2021] [Accepted: 03/03/2021] [Indexed: 01/16/2023]
Abstract
BACKGROUND Hematoma volume in chronic subdural hematoma (CSDH) may predict neurologic deterioration and need for surgical evacuation. Several computer software-assisted methods exist for accurate volume measurements of intracerebral hemorrhage, but no reliable method has been identified for measurement of CSDH volume. METHODS A total of 30 consecutive patients with CSDH from 2018-2019 admitted to our institution were selected. The noncontrast computed tomography head studies were reviewed by 2 residents. The region of interest method on a Horos Open Source Medical Image Viewer (version 3.3.6) was utilized for volume measurement by each resident (resident-1 and resident-2) independently. Resident-1 repeated the protocol on the same studies 1 month later. We calculated the intra- and interobserver reliability of hematoma volume measurements using the Bland-Altman method. RESULTS Mean age of the patients was 79 years (range, 50-92 years). For interobserver analysis, resident-1 mean hematoma volume was 85.46 cm3 (range, 6.40-178.63 cm3) and was 87.15 cm3 (range, 8.79-165.97 cm3) for resident-2. The Bland-Altman coefficient of variation was 13.15% (range, 0.07%-46.29%, 97% within the limits of acceptance). For intraobserver analysis, the initial average volume measured by resident-1 was 85.46 cm3 (range, 6.40-178.63 cm3) and subsequent was 95.26 cm3 (range, 10.48-182.99 cm3). The Bland-Altman coefficient of variation was 13.76% (range, 0.81%-48.34%, 97% within the limits of acceptance). CONCLUSIONS We are reporting inter- and intraobserver reliability for a novel volumetric analysis of CSDH volume using Horos Medical Image Viewer region of interest generated volume calculation. This method is accurate and efficient and could have important clinical and research implications for risk stratification.
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Affiliation(s)
- Farhan Siddiq
- Division of Neurological Surgery, University of Missouri-Columbia School of Medicine, Columbia, Missouri, USA
| | - Navpreet K Bains
- Department of Neurology, University of Missouri-Columbia School of Medicine, Columbia, Missouri, USA.
| | - Joseph P Herbert
- Division of Neurological Surgery, University of Missouri-Columbia School of Medicine, Columbia, Missouri, USA
| | - Iqra N Akhtar
- Department of Neurology, University of Missouri-Columbia School of Medicine, Columbia, Missouri, USA
| | - Ajith J Thomas
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Peter Kan
- Department of Neurosurgery, The University of Texas Medical Branch, Galveston, Texas, USA
| | - Christy Cassarly
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Renee H Martin
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Magdy Selim
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Adnan I Qureshi
- Department of Neurology, University of Missouri-Columbia School of Medicine, Columbia, Missouri, USA; Zeenat Qureshi Stroke Institute, St. Cloud, Minnesota, USA
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17
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Herbal medicine treatment for patients with chronic subdural hematoma: A systematic review and meta-analysis. Complement Ther Clin Pract 2021; 43:101307. [PMID: 33508703 DOI: 10.1016/j.ctcp.2021.101307] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 01/15/2021] [Accepted: 01/18/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND AND PURPOSE In Asian countries, herbal medicines have been used to treat Chronic subdural hematoma (CSDH) as an adjunctive therapy. This review aims to evaluate the efficacy and safety of herbal medicine on treating CSDH and preventing recurrent CSDH. METHODS A literature search was conducted on PubMed, CENTRAL, Scopus, CiNii, KTKP, NDSL, OASIS, and CNKI for randomized controlled trials that evaluated the effects of herbal medicines on CSDH. RESULTS Seven studies (n = 646) were included. The overall methodological quality of these studies was low. In the herbal group, the meta-analysis indicated statistically significant improvements in the total effective rate and recurrence rate as compared with those in the non-herbal group. Herbal treatments were found to be relatively safe. CONCLUSION Herbal medicines might be efficacious in the management of CSDH and prevent its recurrence. Further rigorous studies will have to be conducted in order to make more definite conclusions.
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18
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Won SY, Freiman TM, Reif PS, Dubinski D, Hattingen E, Herrmann E, Seifert V, Rosenow F, Strzelczyk A, Konczalla J. DIagnostic Subdural EEG electrodes And Subdural hEmatoma (DISEASE): a study protocol for a prospective nonrandomized controlled trial. Neurol Res Pract 2020; 2:50. [PMID: 33344885 PMCID: PMC7737265 DOI: 10.1186/s42466-020-00096-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 11/12/2020] [Indexed: 11/16/2022] Open
Abstract
Background Epileptic seizures are common clinical features in patients with acute subdural hematoma (aSDH); however, diagnostic feasibility and therapeutic monitoring remain limited. Surface electroencephalography (EEG) is the major diagnostic tool for the detection of seizures but it might be not sensitive enough to detect all subclinical or nonconvulsive seizures or status epilepticus. Therefore, we have planned a clinical trial to evaluate a novel treatment modality by perioperatively implanting subdural EEG electrodes to diagnose seizures; we will then treat the seizures under therapeutic monitoring and analyze the clinical benefit. Methods In a prospective nonrandomized trial, we aim to include 110 patients with aSDH. Only patients undergoing surgical removal of aSDH will be included; one arm will be treated according to the guidelines of the Brain Trauma Foundation, while the other arm will additionally receive a subdural grid electrode. The study’s primary outcome is the comparison of incidence of seizures and time-to-seizure between the interventional and control arms. Invasive therapeutic monitoring will guide treatment with antiseizure drugs (ASDs). The secondary outcome will be the functional outcome for both groups as assessed via the Glasgow Outcome Scale and modified Rankin Scale both at discharge and during 6 months of follow-up. The tertiary outcome will be the evaluation of chronic epilepsy within 2–4 years of follow-up. Discussion The implantation of a subdural EEG grid electrode in patients with aSDH is expected to be effective in diagnosing seizures in a timely manner, facilitating treatment with ASDs and monitoring of treatment success. Moreover, the occurrence of epileptiform discharges prior to the manifestation of seizure patterns could be evaluated in order to identify high-risk patients who might benefit from prophylactic treatment with ASDs. Trial registration ClinicalTrials.gov identifier no. NCT04211233.
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Affiliation(s)
- Sae-Yeon Won
- Department of Neurosurgery, University Hospital, Goethe University Frankfurt, Schleusenweg 2-16, 60528 Frankfurt am Main, Germany
| | - Thomas M Freiman
- Department of Neurosurgery, University Hospital, Goethe University Frankfurt, Schleusenweg 2-16, 60528 Frankfurt am Main, Germany
| | - Philipp S Reif
- Department of Neurology and Epilepsy Center Frankfurt Rhine-Main, University Hospital, Goethe-University Frankfurt, Frankfurt am Main, Germany.,LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Daniel Dubinski
- Department of Neurosurgery, University Hospital, Goethe University Frankfurt, Schleusenweg 2-16, 60528 Frankfurt am Main, Germany
| | - Elke Hattingen
- Institutes of Neuroradiology, Goethe University, Frankfurt, Germany
| | - Eva Herrmann
- Department of Medicine, Institute of Biostatistics and Mathematical Modelling, Goethe University, Frankfurt am Main, Germany
| | - Volker Seifert
- Department of Neurosurgery, University Hospital, Goethe University Frankfurt, Schleusenweg 2-16, 60528 Frankfurt am Main, Germany
| | - Felix Rosenow
- Department of Neurology and Epilepsy Center Frankfurt Rhine-Main, University Hospital, Goethe-University Frankfurt, Frankfurt am Main, Germany.,LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Adam Strzelczyk
- Department of Neurology and Epilepsy Center Frankfurt Rhine-Main, University Hospital, Goethe-University Frankfurt, Frankfurt am Main, Germany.,LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Juergen Konczalla
- Department of Neurosurgery, University Hospital, Goethe University Frankfurt, Schleusenweg 2-16, 60528 Frankfurt am Main, Germany
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19
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Wan KR, Qiu L, Saffari SE, Khong WXL, Ong JCL, See AA, Ng WH, King NKK. An open label randomized trial to assess the efficacy of tranexamic acid in reducing post-operative recurrence of chronic subdural haemorrhage. J Clin Neurosci 2020; 82:147-154. [PMID: 33317724 DOI: 10.1016/j.jocn.2020.10.053] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 10/09/2020] [Accepted: 10/21/2020] [Indexed: 01/26/2023]
Abstract
Chronic subdural haemorrhage (CSDH) is a common neurosurgical entity with complex pathophysiological pathways. The generally favourable surgical outcome may be affected by its associated risks including recurrence rates. We performed a prospective randomized multi-center clinical trial comparing the addition of tranexamic acid (TXA) to standard neurosurgical procedures for patients with symptomatic CSDH. The primary endpoint was CSDH requiring repeat surgery within 6-month post-operatively. Secondary endpoints were comparison of post-operative volumes between the treatment arms and safety evaluation of the dosing regime. 90 patients were analyzed with 49 patients in the observation arm and 41 patients in the TXA arm. The observation arm had five (10.2%) recurrences compared to two (4.8%, p = 0.221) in the TXA arm. Patients in the TXA arm demonstrated a greater reduction of their CSDH volume at 6 weeks follow up (36.6%) compared to the observation arm (23.3%, p = 0.6648). There were no reportable serious adverse events recorded in the observation arm, compared to 4 (9.8%) patients in the TXA arm. The addition of TXA treatment to standard surgical drainage of CSH did not significantly reduce symptomatic post-operative recurrence. Patients in the TXA arm had a delay in the CSDH recurrence with a comparative reduction of residual hematoma volume at the 6-week follow up although the effect was unsustained. Larger randomized trials with dose adjustments should be considered to investigate subgroups of patients that may benefit from this medical adjunct.
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Affiliation(s)
- Kai Rui Wan
- Department of Neurosurgery, National Neuroscience Institute, Singapore; Department of Neurosurgery, Singapore General Hospital, Singapore.
| | - Liming Qiu
- Department of Neurosurgery, National Neuroscience Institute, Singapore; Department of Neurosurgery, Singapore General Hospital, Singapore.
| | | | | | | | - Angela Anqi See
- Department of Neurosurgery, National Neuroscience Institute, Singapore; Department of Neurosurgery, Singapore General Hospital, Singapore
| | - Wai Hoe Ng
- Department of Neurosurgery, National Neuroscience Institute, Singapore; Department of Neurosurgery, Singapore General Hospital, Singapore.
| | - Nicolas Kon Kam King
- Department of Neurosurgery, National Neuroscience Institute, Singapore; Department of Neurosurgery, Singapore General Hospital, Singapore
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20
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Kutty RK, Leela SK, Sreemathyamma SB, Sivanandapanicker JL, Asher P, Peethambaran A, Prabhakar RB. The Outcome of Medical Management of Chronic Subdural Hematoma with Tranexamic Acid – A Prospective Observational Study. J Stroke Cerebrovasc Dis 2020; 29:105273. [DOI: 10.1016/j.jstrokecerebrovasdis.2020.105273] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 08/13/2020] [Accepted: 08/21/2020] [Indexed: 11/26/2022] Open
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21
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Tommiska P, Raj R, Schwartz C, Kivisaari R, Luostarinen T, Satopää J, Taimela S, Järvinen T, Ranstam J, Frantzen J, Posti J, Luoto TM, Leinonen V, Tetri S, Koivisto T, Lönnrot K. Finnish study of intraoperative irrigation versus drain alone after evacuation of chronic subdural haematoma (FINISH): a study protocol for a multicentre randomised controlled trial. BMJ Open 2020; 10:e038275. [PMID: 32565480 PMCID: PMC7311024 DOI: 10.1136/bmjopen-2020-038275] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Chronic subdural haematomas (CSDHs) are one of the most common neurosurgical conditions. The goal of surgery is to alleviate symptoms and minimise the risk of symptomatic recurrences. In the past, reoperation rates as high as 20%-30% were described for CSDH recurrences. However, following the introduction of subdural drainage, reoperation rates dropped to approximately 10%. The standard surgical technique includes burr-hole craniostomy, followed by intraoperative irrigation and placement of subdural drainage. Yet, the role of intraoperative irrigation has not been established. If there is no difference in recurrence rates between intraoperative irrigation and no irrigation, CSDH surgery could be carried out faster and more safely by omitting the step of irrigation. The aim of this multicentre randomised controlled trial is to study whether no intraoperative irrigation and subdural drainage results in non-inferior outcome compared with intraoperative irrigation and subdural drainage following burr-hole craniostomy of CSDH. METHODS AND ANALYSIS This is a prospective, randomised, controlled, parallel group, non-inferiority multicentre trial comparing single burr-hole evacuation of CSDH with intraoperative irrigation and evacuation of CSDH without irrigation. In both groups, a passive subdural drain is used for 48 hours as a standard of treatment. The primary outcome is symptomatic CSDH recurrence requiring reoperation within 6 months. The predefined non-inferiority margin for the primary outcome is 7.5%. To achieve a 2.5% level of significance and 80% power, we will randomise 270 patients per group. Secondary outcomes include modified Rankin Scale, rate of mortality, duration of operation, length of hospital stay, adverse events and change in volume of CSDH. ETHICS AND DISSEMINATION The study was approved by the institutional review board of the Helsinki and Uusimaa Hospital District (HUS/3035/2019 §238) and duly registered at ClinicalTrials.gov. We will disseminate the findings of this study through peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER NCT04203550.
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Affiliation(s)
- Pihla Tommiska
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Uusimaa, Finland
| | - Rahul Raj
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Uusimaa, Finland
| | - Christoph Schwartz
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Uusimaa, Finland
- Department of Neurosurgery, University Hospital Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Riku Kivisaari
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Uusimaa, Finland
| | - T Luostarinen
- Division of Anaesthesiology, Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Uusimaa, Finland
| | - Jarno Satopää
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Uusimaa, Finland
| | - Simo Taimela
- Finland and Finnish Centre for Evidence-Based Orthopedics (FICEBO), University of Helsinki, Helsinki, Finland
- Department of Orthopaedics and Traumatology, University of Helsinki and Helsinki University Hospital, Helsinki, Uusimaa, Finland
| | - Teppo Järvinen
- Finland and Finnish Centre for Evidence-Based Orthopedics (FICEBO), University of Helsinki, Helsinki, Finland
- Department of Orthopaedics and Traumatology, University of Helsinki and Helsinki University Hospital, Helsinki, Uusimaa, Finland
| | | | - Janek Frantzen
- Division of Clinical Neurosciences, Department of Neurosurgery and Turku Brain Centre, Turku University Hospital and University of Turku, Turku, Finland
| | - Jussi Posti
- Division of Clinical Neurosciences, Department of Neurosurgery and Turku Brain Centre, Turku University Hospital and University of Turku, Turku, Finland
| | - Teemu M Luoto
- Department of Neurosurgery, Tampere University Hospital and Tampere University, Tampere, Finland
| | - Ville Leinonen
- Department of Neurosurgery, Kuopio University Hospital and University of Eastern Finland, Kuopio, Pohjois-Savo, Finland
| | - Sami Tetri
- Unit of Clinical Neuroscience, Neurosurgery, University of Oulu and Medical Research Center, Oulu, Finland
| | - Timo Koivisto
- Department of Neurosurgery, Kuopio University Hospital and University of Eastern Finland, Kuopio, Pohjois-Savo, Finland
| | - Kimmo Lönnrot
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Uusimaa, Finland
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22
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Jiang R, Zhao S, Wang R, Feng H, Zhang J, Li X, Mao Y, Yuan X, Fei Z, Zhao Y, Yu X, Poon WS, Zhu X, Liu N, Kang D, Sun T, Jiao B, Liu X, Yu R, Zhang J, Gao G, Hao J, Su N, Yin G, Zhu X, Lu Y, Wei J, Hu J, Hu R, Li J, Wang D, Wei H, Tian Y, Lei P, Dong JF, Zhang J. Safety and Efficacy of Atorvastatin for Chronic Subdural Hematoma in Chinese Patients: A Randomized ClinicalTrial. JAMA Neurol 2019; 75:1338-1346. [PMID: 30073290 DOI: 10.1001/jamaneurol.2018.2030] [Citation(s) in RCA: 153] [Impact Index Per Article: 30.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Chronic subdural hematoma (CSDH) is a trauma-associated condition commonly found in elderly patients. Surgery is currently the treatment of choice, but it carries a significant risk of recurrence and death. Nonsurgical treatments remain limited and ineffective. Our recent studies suggest that atorvastatin reduces hematomas and improves the clinical outcomes of patients with CSDH. Objective To investigate the safety and therapeutic efficacy of atorvastatin to nonsurgically treat patients with CSDH. Design, Setting, and Participants The Effect of Atorvastatin on Chronic Subdural Hematoma (ATOCH) randomized, placebo-controlled, double-blind phase II clinical trial was conducted in multiple centers in China from February 2014 to November 2015. For this trial, we approached 254 patients with CSDH who received a diagnosis via a computed tomography scan; of these, 200 (78.7%) were enrolled because 23 patients (9.1%) refused to participate and 31 (12.2%) were disqualified. Interventions Patients were randomly assigned to receive either 20 mg of atorvastatin or placebo daily for 8 weeks and were followed up for an additional 16 weeks. Main Outcomes and Measures The primary outcome was change in hematoma volume (HV) by computed tomography after 8 weeks of treatment. The secondary outcomes included HV measured at the 4th, 12th, and 24th weeks and neurological function that was evaluated using the Markwalder grading scale/Glasgow Coma Scale and the Barthel Index at the 8th week. Results One hundred ninety-six patients received treatment (169 men [86.2%]; median [SD] age, 63.6 [14.2] years). The baseline HV and clinical presentations were similar between patients who were taking atorvastatin (98 [50%]) and the placebo (98 [50%]). After 8 weeks, the HV reduction in patients who were taking atorvastatin was 12.55 mL more than those taking the placebo (95% CI, 0.9-23.9 mL; P = .003). Forty-five patients (45.9%) who were taking atorvastatin significantly improved their neurological function, but only 28 (28.6%) who were taking the placebo did, resulting in an adjusted odds ratio of 1.957 for clinical improvements (95% CI, 1.07-3.58; P = .03). Eleven patients (11.2%) who were taking atorvastatin and 23 (23.5%) who were taking the placebo underwent surgery during the trial for an enlarging hematoma and/or a deteriorating clinical condition (hazard ratio, 0.47; 95% CI, 0.24-0.92; P = .03). No significant adverse events were reported. Conclusions and Relevance Atorvastatin may be a safe and efficacious nonsurgical alternative for treating patients with CSDH. Trial Registration ClinicalTrials.gov Identifier: NCT02024373.
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Affiliation(s)
- Rongcai Jiang
- Key Laboratory of Post-Neurotrauma Neurorepair and Regeneration in Central Nervous System, Ministry of Education in China and Tianjin, Tianjin Neurological Institute, Tianjin, China
| | - Shiguang Zhao
- Department of Neurosurgery, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Renzhi Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Beijing, China
| | - Hua Feng
- Department of Neurosurgery, Southwest Hospital, Chongqing, China
| | - Jianmin Zhang
- Department of Neurosurgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xingang Li
- Department of Neurosurgery, Qilu Hospital of Shandong University, Jinan, China
| | - Ying Mao
- Department of Neurosurgery, Huashan Hospital Fudan University, Shanghai, China
| | - Xianrui Yuan
- Department of Neurosurgery, Xiangya Hospital of Central South University, Changsha, China
| | - Zhou Fei
- Department of Neurosurgery, Xijing Hospital, Xian, China
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing TianTan Hospital, the Capital Medical University, Beijing, China
| | - Xinguang Yu
- Department of Neurosurgery, General Hospital of Chinese People's Liberation Army, Beijing, China
| | - Wai Sang Poon
- Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Shatin, Hong Kong
| | - Xide Zhu
- Department of Neurosurgery, Linyi People's Hospital, Linyi, China
| | - Ning Liu
- Department of Neurosurgery, Jiangsu Provincial Hospital, Nanjing Medical University First Affiliated Hospital, Nanjing, China
| | - Dezhi Kang
- Department of Neurosurgery, First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Tao Sun
- Department of Neurosurgery, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Baohua Jiao
- Department of Neurosurgery, Second Affiliated Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xianzhi Liu
- Department of Neurosurgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Rutong Yu
- Department of Neurosurgery, Affiliated Hospital of Xuzhou Medical College, Xuzhou, China
| | - Junyi Zhang
- Department of Neurosurgery, Central Hospital of Erdos, Erdos, China
| | - Guodong Gao
- Department of Neurosurgery, Xi'an Tangdu Hospital of the fourth Military Medical University, Xian, China
| | - Jiehe Hao
- Department of Neurosurgery, First Affiliated Hospital of Shanxi Medical University, Taiyuan, China
| | - Ning Su
- Department of Neurosurgery, Provincial People's Hospital of Inner Mongolia, Huhehot, China
| | - Gangfeng Yin
- Department of Neurosurgery, Cangzhou Central Hospital, Cangzhou, China
| | - Xingen Zhu
- Department of Neurosurgery, Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yicheng Lu
- Department of Neurosurgery, Shanghai Changzheng Hospital, Shanghai, China
| | - Junji Wei
- Department of Neurosurgery, Peking Union Medical College Hospital, Beijing, China
| | - Jin Hu
- Department of Neurosurgery, Huashan Hospital Fudan University, Shanghai, China
| | - Rong Hu
- Department of Neurosurgery, Southwest Hospital, Chongqing, China
| | - Jianrong Li
- Department of Neurosurgery, 117th Hospital of Chinese People's Liberation Army, Hangzhou, China
| | - Dong Wang
- Key Laboratory of Post-Neurotrauma Neurorepair and Regeneration in Central Nervous System, Ministry of Education in China and Tianjin, Tianjin Neurological Institute, Tianjin, China
| | - Huijie Wei
- Key Laboratory of Post-Neurotrauma Neurorepair and Regeneration in Central Nervous System, Ministry of Education in China and Tianjin, Tianjin Neurological Institute, Tianjin, China
| | - Ye Tian
- Key Laboratory of Post-Neurotrauma Neurorepair and Regeneration in Central Nervous System, Ministry of Education in China and Tianjin, Tianjin Neurological Institute, Tianjin, China
| | - Ping Lei
- Laboratory of Neuro-Trauma and Neurodegenerative Disorders, Tianjin Geriatrics Institute, Tianjin Medical University General Hospital, Tianjin, China.,Department of Geriatrics, Tianjin Medical University General Hospital, Tianjin, China
| | - Jing-Fei Dong
- Bloodworks Research Institute, Division of Hematology, Department of Medicine, University of Washington School of Medicine, Seattle
| | - Jianning Zhang
- Key Laboratory of Post-Neurotrauma Neurorepair and Regeneration in Central Nervous System, Ministry of Education in China and Tianjin, Tianjin Neurological Institute, Tianjin, China
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Levesque M, Iorio-Morin C, Bocti C, Vézina C, Deacon C. Nonepileptic, Stereotypical, and Intermittent Symptoms (NESIS) in Patients With Subdural Hematoma: Proposal for a New Clinical Entity With Therapeutic and Prognostic Implications. Neurosurgery 2019; 87:96-103. [DOI: 10.1093/neuros/nyz355] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 06/27/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Transient neurological symptoms (TNS) are frequent in patients with subdural hematomas (SDH) and many will receive a diagnosis of epilepsy despite a negative workup.
OBJECTIVE
To explore if patients with TNS and a negative epilepsy workup (cases) evolved differently than those with a positive EEG (controls), which would suggest the existence of alternative etiologies for TNS.
METHODS
We performed a single-center, retrospective, case-control study of patients with TNS post-SDH. The demographics and clinical and semiological features of cases and controls were compared. The outcome and response to antiepileptic drugs were also assessed and a scoring system developed to predict negative EEG.
RESULTS
Fifty-nine patients with SDH-associated TNS were included (39 cases and 20 controls). Demographic characteristics were comparable in both groups. Dysphasia and prolonged episodes were associated with a negative EEG. Clonic movements, impaired awareness, positive symptomatology, complete response to antiepileptic drugs, and mortality were associated with a positive EEG. Using semiological variables, we created a scoring system with a 96.6% sensitivity and 100% specificity in predicting case group patients. The differences observed between both groups support the existence of an alternative etiology to seizures in our case group. We propose the term NESIS (NonEpileptic, Stereotypical, and Intermittent Symptoms) to refer to this subgroup and hypothesize that TNS in these patients might result from cortical spreading depolarization.
CONCLUSION
We describe NESIS as a syndrome experienced by SDH patients with specific prognostic and therapeutic implications. Independent validation of this new entity is now required.
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Affiliation(s)
- Mathieu Levesque
- Division of Neurology, Department of Medicine, Université de Sherbrooke, Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Canada
| | - Christian Iorio-Morin
- Division of Neurosurgery, Department of Surgery, Université de Sherbrooke, Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Canada
| | - Christian Bocti
- Division of Neurology, Department of Medicine, Université de Sherbrooke, Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Canada
| | - Caroline Vézina
- Division of Family Medicine, Department of Family Medicine, Université de Sherbrooke, Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Canada
| | - Charles Deacon
- Division of Neurology, Department of Medicine, Université de Sherbrooke, Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Canada
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Court J, Touchette CJ, Iorio-Morin C, Westwick HJ, Belzile F, Effendi K. Embolization of the Middle meningeal artery in chronic subdural hematoma - A systematic review. Clin Neurol Neurosurg 2019; 186:105464. [PMID: 31600604 DOI: 10.1016/j.clineuro.2019.105464] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 07/09/2019] [Accepted: 08/06/2019] [Indexed: 12/15/2022]
Abstract
Chronic subdural hematomas (cSDH) are one of the most frequent reasons for consultation in neurosurgery. Multiple authors have proposed middle meningeal artery embolization (MMAE) as an option in cSDH patients to manage recurrence or avoid surgery altogether. Although many articles have been published on the matter, the current body of evidence still has to be evaluated before MMAE is integrated into clinical practice. The goal of this study was to review the evidence on MMAE in cSDH to assess its safety, feasibility, indications and efficacy. We performed a systematic review of the literature according to PRISMA guidelines using multiple electronic databases. Our search yielded a total of 18 original articles from which data were extracted. A total of 190 patients underwent MMAE from which 81.3% were symptomatic cSDH. Over half (52.3%) of the described population were undergoing antithrombotic therapy. Most (83%) procedures used polyvinyl alcohol (PVA) particles and no complications were reported regarding the embolization procedures. Although the definition of resolution varied among authors, cSDH resolution was reported in 96.8% of cases. MMAE is a feasible technique for cSDH, but the current body of evidence does not yet support its use as a standard treatment. Further studies with a higher level of evidence are necessary before MMAE can be formally recommended.
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Affiliation(s)
- Jordan Court
- Department of radiology, Université de Sherbrooke, Québec, Canada.
| | - Charles J Touchette
- Division of neurosurgery, Department of surgery, Université de Sherbrooke, Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Christian Iorio-Morin
- Division of neurosurgery, Department of surgery, Université de Sherbrooke, Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Harrison J Westwick
- Division of neurosurgery, Department of surgery, Université de Montreal, Centre hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - François Belzile
- Department of radiology, Université de Sherbrooke, Québec, Canada
| | - Khaled Effendi
- Division of neurosurgery, Department of surgery, Université de Sherbrooke, Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
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25
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Kumar A, Yadav YR. Letter to the Editor. Factors predicting reoperation for chronic subdural hematoma. J Neurosurg 2019; 130:1784-1786. [PMID: 30835698 DOI: 10.3171/2018.11.jns183191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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26
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Fernandes de Oliveira M. Chronic Subdural Hematomas and Pursuit of Nonsurgical Treatment Alternatives. World Neurosurg 2019; 126:481-483. [PMID: 30922902 DOI: 10.1016/j.wneu.2019.03.151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Accepted: 03/04/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Matheus Fernandes de Oliveira
- Hospital do Servidor Público Estadual de São Paulo, São Paulo, Brazil; Hospital das Clínicas da Faculdade de Medicina da USP, São Paulo, Brazil; DFV Neuro, São Paulo, Brazil.
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27
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Chan DYC, Tsang ACO, Li LF, Cheng KKF, Tsang FCP, Taw BBT, Pu JKS, Ho WWS, Lui WM, Leung GKK. Improving Survival with Tranexamic Acid in Cerebral Contusions or Traumatic Subarachnoid Hemorrhage: Univariate and Multivariate Analysis of Independent Factors Associated with Lower Mortality. World Neurosurg 2019; 125:e665-e670. [PMID: 30721773 DOI: 10.1016/j.wneu.2019.01.145] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Revised: 01/23/2019] [Accepted: 01/24/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Fall with head injury is a pervasive challenge, especially in the aging population. Contributing factors for mortality include the development of cerebral contusions and delayed traumatic intracerebral hematoma. Currently, there is no established specific treatment for these conditions. OBJECT This study aimed to investigate the impact of independent factors on the mortality rate of traumatic brain injury with contusions or traumatic subarachnoid hemorrhage. METHODS Data were collected from consecutive patients admitted for cerebral contusions or traumatic subarachnoid hemorrhage at an academic trauma center from 2010 to 2016. The primary outcome was the 30-day mortality rate. Independent factors for analysis included patient factors and treatment modalities. Univariate and multivariate analyses were conducted to identify independent factors related to mortality. Secondary outcomes included thromboembolic complication rates associated with the use of tranexamic acid. RESULTS In total, 651 consecutive patients were identified. For the patient factors, low Glasgow Coma Scale on admission, history of renal impairment, and use of warfarin were identified as independent factors associated with higher mortality from univariate and multivariate analyses. For the treatment modalities, univariate analysis identified tranexamic acid as an independent factor associated with lower mortality (P = 0.021). Thromboembolic events were comparable in patients with or without tranexamic acid. CONCLUSION Tranexamic acid was identified by univariate analysis as an independent factor associated with lower mortality in cerebral contusions or traumatic subarachnoid hemorrhage. Further prospective studies are needed to validate this finding.
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Affiliation(s)
- David Yuen Chung Chan
- Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong
| | - Anderson Chun On Tsang
- Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong
| | - Lai Fung Li
- Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong
| | - Kevin King Fai Cheng
- Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong
| | - Frederick Chun Pong Tsang
- Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong
| | - Benedict Beng Teck Taw
- Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong
| | - Jenny Kan Suen Pu
- Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong
| | - Wilson Wai Shing Ho
- Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong
| | - Wai Man Lui
- Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong
| | - Gilberto Ka Kit Leung
- Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong.
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Abstract
A warning leak is a curious phenomenon attributed to cerebral aneurysms. Once the leak occurs, it has been postulated it could lead to a more catastrophic rebleeding. The designation "warning leak" trickled into neurosurgery vocabulary as early as the 1950s. The phenomenon has been poorly understood and characterized, but its presence spurs emergency physicians and neurointensivists to take action to secure the aneurysm. Rapid treatment of a recently discovered aneurysm is now commonplace, but it has not always been so. Antifibrinolytic agents spawned particular interest in the late 1970s, when many neurosurgeons postponed surgery after a recent hemorrhage. This historical vignette reviews the early views on aneurysmal rupture, rerupture, and the role of fibrinolysis.
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Affiliation(s)
- Eelco F M Wijdicks
- Division of Critical Care Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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29
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Iorio-Morin C, Touchette C, Lévesque M, Effendi K, Fortin D, Mathieu D. Chronic Subdural Hematoma: Toward a New Management Paradigm for an Increasingly Complex Population. J Neurotrauma 2018; 35:1882-1885. [DOI: 10.1089/neu.2018.5872] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- Christian Iorio-Morin
- Division of Neurosurgery, Department of Surgery, Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Charles Touchette
- Division of Neurosurgery, Department of Surgery, Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Mathieu Lévesque
- Division of Neurology, Department of Medicine, Université de Sherbrooke, Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - Khaled Effendi
- Division of Neurosurgery, Department of Surgery, Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - David Fortin
- Division of Neurosurgery, Department of Surgery, Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
| | - David Mathieu
- Division of Neurosurgery, Department of Surgery, Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Québec, Canada
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Abstract
PURPOSE OF REVIEW Subdural hematomas (SDH) represent common neurosurgical problem associated with significant morbidity, mortality, and high recurrence rates. SDH incidence increases with age; numbers of patients affected by SDH continue to rise with our aging population and increasing number of people taking antiplatelet agents or anticoagulation. Medical and surgical SDH management remains a subject of investigation. RECENT FINDINGS Initial management of patients with concern for altered mental status with or without trauma starts with Emergency Neurological Life Support (ENLS) guidelines, with a focus on maintaining ICP < 22 mmHg, CPP > 60 mmHg, MAP 80-110 mmHg, and PaO2 > 60 mmHg, followed by rapid sequence intubation if necessary, and expedited acquisition of imaging to identify a space-occupying lesion. Patients are administered anti-seizure medications, and their antiplatelet medications or anticoagulation may be reversed if neurosurgical interventions are anticipated, or until hemorrhage is stabilized on imaging. Medical SDH care focuses on (a) management of intracranial hypertension; (b) maintenance of adequate cerebral perfusion; (c) seizure prevention and treatment; (d) maintenance of normothermia, eucarbia, euglycemia, and euvolemia; and (e) early initiation of enteral feeding, mobilization, and physical therapy. Post-operatively, SDH patients require ICU level care and are co-managed by neurointensivists with expertise in treating increased intracranial pressure, seizures, and status epilepticus, as well as medical complications of critical illness. Here, we review various aspects of medical management with a brief overview of pertinent literature and clinical trials for patients diagnosed with SDH.
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31
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Holl DC, Volovici V, Dirven CMF, Peul WC, van Kooten F, Jellema K, van der Gaag NA, Miah IP, Kho KH, den Hertog HM, Lingsma HF, Dammers R. Pathophysiology and Nonsurgical Treatment of Chronic Subdural Hematoma: From Past to Present to Future. World Neurosurg 2018; 116:402-411.e2. [PMID: 29772364 DOI: 10.1016/j.wneu.2018.05.037] [Citation(s) in RCA: 108] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Accepted: 05/05/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND Chronic subdural hematoma (CSDH) is one of the more frequent pathologic entities in daily neurosurgical practice. Historically, CSDH was considered progressive recurrent bleeding with a traumatic cause. However, recent evidence has suggested a complex intertwined pathway of inflammation, angiogenesis, local coagulopathy, recurrent microbleeds, and exudates. The aim of the present review is to collect existing data on pathophysiology of CSDH to direct further research questions aiming to optimize treatment for the individual patient. METHODS We performed a thorough literature search in PubMed, Ovid, EMBASE, CINAHL, and Google scholar, focusing on any aspect of the pathophysiology and nonsurgical treatment of CSDH. RESULTS After a (minor) traumatic event, the dural border cell layer tears, which leads to the extravasation of cerebrospinal fluid and blood in the subdural space. A cascade of inflammation, impaired coagulation, fibrinolysis, and angiogenesis is set in motion. The most commonly used treatment is surgical drainage. However, because of the pathophysiologic mechanisms, the mortality and high morbidity associated with surgical drainage, drug therapy (dexamethasone, atorvastatin, tranexamic acid, or angiotensin-converting enzyme inhibitors) might be a beneficial alternative in many patients with CSDH. CONCLUSIONS Based on pathophysiologic mechanisms, animal experiments, and small patient studies, medical treatment may play a role in the treatment of CSDH. There is a lack of level I evidence in the nonsurgical treatment of CSDH. Therefore, randomized controlled trials, currently lacking, are needed to assess which treatment is most effective in each individual patient.
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Affiliation(s)
- Dana C Holl
- Department of Neurosurgery, Erasmus Medical Center, Erasmus MC Stroke Center, Rotterdam, The Netherlands.
| | - Victor Volovici
- Department of Neurosurgery, Erasmus Medical Center, Erasmus MC Stroke Center, Rotterdam, The Netherlands; Department of Public Health and Medical Decision Making, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Clemens M F Dirven
- Department of Neurosurgery, Erasmus Medical Center, Erasmus MC Stroke Center, Rotterdam, The Netherlands
| | - Wilco C Peul
- Department of Neurosurgery, Leiden University Medical Center, Leiden, Haaglanden MC and Haga Teaching Hospital, The Hague, The Netherlands
| | - Fop van Kooten
- Department of Neurology, Erasmus Medical Center, Erasmus MC Stroke Center, Rotterdam, The Netherlands
| | - Korné Jellema
- Department of Neurology, Haaglanden Medical Center, The Hague, The Netherlands
| | - Niels A van der Gaag
- Department of Neurosurgery, Leiden University Medical Center, Leiden, Haaglanden MC and Haga Teaching Hospital, The Hague, The Netherlands
| | - Ishita P Miah
- Department of Neurology, Haaglanden Medical Center, The Hague, The Netherlands
| | - Kuan H Kho
- Department of Neurosurgery, Medisch Spectrum Twente, Enschede, The Netherlands
| | | | - Hester F Lingsma
- Department of Public Health and Medical Decision Making, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Ruben Dammers
- Department of Neurosurgery, Erasmus Medical Center, Erasmus MC Stroke Center, Rotterdam, The Netherlands
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Lu W, Wang H, Wu T, Sheng X, Ding Z, Xu G. Burr-Hole Craniostomy with T-Tube Drainage as Surgical Treatment for Chronic Subdural Hematoma. World Neurosurg 2018; 115:e756-e760. [PMID: 29729458 DOI: 10.1016/j.wneu.2018.04.168] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Revised: 04/22/2018] [Accepted: 04/23/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE We sought to investigate the effect of burr-hole craniostomy with T-tube drainage to treat chronic subdural hematoma (CSDH). METHODS Eighty-seven patients with CSDH who were recruited from January 2012 to June 2017 at the Department of Neurosurgery, The First Affiliated Hospital of Xi'an Medical University, were divided into 2 groups according to the method of drainage: T-tube drainage system (n = 45) and conventional subdural drainage system (n = 42). Retrospective analysis of clinical data and efficacy was performed between the 2 groups. RESULTS There were no significant differences in age, preoperative Markwalder grade scale, preoperative hematoma volume, hospitalization days, and discharge Markwalder grade scale between the 2 groups (P > 0.05). The incidence of postoperative complications and hematoma recurrence in the group of patients with T-tube drainage was significantly reduced when compared with conventional subdural drainage systems (P < 0.05). CONCLUSIONS Both methods were effective in the treatment of CSDH; however, we found a lower overall surgical complication rate following treatment with burr-hole craniostomy and T-tube drainage. This indicates that it may be a better therapeutic option for management of CSDH.
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Affiliation(s)
- Wenchao Lu
- Department of Neurosurgery, The First Affiliated Hospital of Xi'an Medical University, Xi'an, Shaanxi Province, China.
| | - Hui Wang
- Department of Neurosurgery, The First Affiliated Hospital of Xi'an Medical University, Xi'an, Shaanxi Province, China
| | - Tao Wu
- Department of Neurosurgery, The First Affiliated Hospital of Xi'an Medical University, Xi'an, Shaanxi Province, China
| | - Xudong Sheng
- Department of Neurosurgery, The First Affiliated Hospital of Xi'an Medical University, Xi'an, Shaanxi Province, China
| | - Zhibin Ding
- Department of Neurosurgery, The First Affiliated Hospital of Xi'an Medical University, Xi'an, Shaanxi Province, China
| | - Gangzhu Xu
- Department of Neurosurgery, The First Affiliated Hospital of Xi'an Medical University, Xi'an, Shaanxi Province, China
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33
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Welling LC, Welling MS, Teixeira MJ, Figueiredo EG. Chronic Subdural Hematoma: So Common and So Neglected. World Neurosurg 2018; 111:393-394. [PMID: 29366996 DOI: 10.1016/j.wneu.2018.01.131] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Leonardo C Welling
- Department of Neurological Surgery, State University of Ponta Grossa, Ponta Grossa, Parana, Brazil
| | - Mariana S Welling
- Department of Neurology, State University of Ponta Grossa, Ponta Grossa, Parana, Brazil
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[Prophylactic use of tranexamic acid in noncardiac surgery : Update 2017]. Med Klin Intensivmed Notfmed 2018; 114:642-649. [PMID: 29368267 DOI: 10.1007/s00063-018-0402-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 11/08/2017] [Accepted: 12/09/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Minimising perioperative bleeding is a key goal of "patient blood management" programs. One component of respective strategies includes preventive inhibition of fibrinolysis using protease inhibitors, such as tranexamic acid (TXA). TXA inhibits plasminogen activation and plasmin-induced fibrin degradation. OBJECTIVES The present article provides an overview of the existing literature and TXA applications in the prophylaxis of perioperative bleeding. METHODS Literature search in PubMed/MEDLINE (U.S. National Library of Medicine®, Bethesda, MD, USA). RESULTS TXA reduces perioperative blood loss and transfusion requirements in several randomized controlled trials (RCTs) and meta-analyses in the field of hip and knee arthroplasty for both intravenous and topical use. Moreover, evidence favours use of TXA in complex spine surgery and reconstructive surgery (e. g. craniosynostosis in children). Single RCTs showed benefits of TXA in abdominal hysterectomy, open prostatectomy, liver surgery and actively bleeding trauma patients. For prophylaxis of peripartum haemorrhage (PPH) following vaginal delivery or Caesarean section, TXA cannot be routinely recommended, although evidence points to benefits in actively bleeding patients. A recommendation exists for the treatment of (active) PPH. For prophylactic perioperative administration, different dosage regimens exist for adults. Most often an initial i. v. bolus of 1 g or 10-15 mg/kg body weight with/without repetition after 6 h or continuous infusions over 8 h is administered. Increased rates of thromboembolic events were not noted. CONCLUSION Protease inhibitors such as TXA reduce perioperative blood loss and transfusion requirements in selected surgical fields.
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Abstract
Surgery is the standard treatment for chronic subdural hematoma (CSDH), one of the common problems in neurosurgical practice. Although medical treatment was used by some authors and found some positive results, it is not accepted by many authors. The aim of this review is to give overall view of the medical management of CSDH. Action of various drugs in the pathophysiological cascade of formation of CSDH was depicted. The review of literature is done under three headings – the primary medical treatment of CSDH, adjuvant medical treatment with surgery, and the treatment of the recurrence. Various classifications of CSDH and the factors influencing the outcome of medical treatment are discussed. There is a role of medical treatment in a selected group of patients with CSDH. Well-designed, multicenter, randomized controlled trials are required to define the indications and standard protocols for the medical treatment of CSDH.
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Affiliation(s)
- Amit Kumar Thotakura
- Department of Neurosurgery, NRI Academy of Sciences, Guntur, Andhra Pradesh, India
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36
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Mikkelsen R, Anker-Møller T, Hvas AM, Sunde N. A Case of Tranexamic Acid as Adjunctive Treatment for Chronic Subdural Hematoma with Multiple Recurrences. AMERICAN JOURNAL OF CASE REPORTS 2017; 18:995-999. [PMID: 28912416 PMCID: PMC5612033 DOI: 10.12659/ajcr.904117] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Patient: Male, 64 Final Diagnosis: Chronic subdural hematoma Symptoms: Aphasia • headache • paresis Medication: — Clinical Procedure: Burr hole evacuation • Tranexamic acid Specialty: Neurosurgery
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Affiliation(s)
- Ronni Mikkelsen
- Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
| | - Thorkil Anker-Møller
- Centre for Haemophilia and Thrombosis, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - Anne-Mette Hvas
- Centre for Haemophilia and Thrombosis, Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - Niels Sunde
- Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
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Predictors of Recurrence and Complications After Chronic Subdural Hematoma Surgery: A Population-Based Study. World Neurosurg 2017; 106:609-614. [PMID: 28735129 DOI: 10.1016/j.wneu.2017.07.044] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 07/09/2017] [Accepted: 07/11/2017] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To investigate predictors of recurrence and moderate to severe complications after burr-hole surgery for chronic subdural hematoma (cSDH). METHODS A retrospective review was conducted in a Scandinavian single-center population-based cohort of 759 adult patients with cSDH operated with burr-hole surgery between January 1, 2005 and December 31, 2010. Possible predictors of recurrence and complications, assessed using a standardized reporting system of adverse events, were identified and analyzed in univariable analyses. Variables with a P value < 0.10 were included in a multivariable regression model. RESULTS Recurrence was observed in 85 patients (11.2%), whereas moderate to severe complications were observed in 35 patients (4.6%). Bilateral hematoma (odds ratio [OR], 2.05; 95% confidence interval [CI], 1.25-3.35; P < 0.01) and largest hematoma diameter in millimeters (OR, 1.05; 95% CI, 1.01-1.09; P < 0.01) were independent predictors of recurrence in the multivariable model analysis. Glasgow Coma Scale (GCS) score of <13 (OR, 6.06; 95% CI, 2.72-13.51; P < 0.01) and Charlson Comorbidity Index (CCI) >1 (OR, 2.28; 95% CI, 1.10-4.75; P = 0.03) were independent predictors of moderate to severe complications. CONCLUSIONS Recurrence after cSDH surgery is more often encountered in patients with radiologically more extensive disease reflected by bilateral hematoma and large hematoma diameter. On the other hand, moderate to severe complications are more often seen in patients in a worse clinical condition, reflected by decreased level of consciousness and more comorbidities.
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Edlmann E, Giorgi-Coll S, Whitfield PC, Carpenter KLH, Hutchinson PJ. Pathophysiology of chronic subdural haematoma: inflammation, angiogenesis and implications for pharmacotherapy. J Neuroinflammation 2017; 14:108. [PMID: 28558815 PMCID: PMC5450087 DOI: 10.1186/s12974-017-0881-y] [Citation(s) in RCA: 321] [Impact Index Per Article: 45.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 05/15/2017] [Indexed: 02/08/2023] Open
Abstract
Chronic subdural haematoma (CSDH) is an encapsulated collection of blood and fluid on the surface of the brain. Historically considered a result of head trauma, recent evidence suggests there are more complex processes involved. Trauma may be absent or very minor and does not explain the progressive, chronic course of the condition. This review focuses on several key processes involved in CSDH development: angiogenesis, fibrinolysis and inflammation. The characteristic membrane surrounding the CSDH has been identified as a source of fluid exudation and haemorrhage. Angiogenic stimuli lead to the creation of fragile blood vessels within membrane walls, whilst fibrinolytic processes prevent clot formation resulting in continued haemorrhage. An abundance of inflammatory cells and markers have been identified within the membranes and subdural fluid and are likely to contribute to propagating an inflammatory response which stimulates ongoing membrane growth and fluid accumulation. Currently, the mainstay of treatment for CSDH is surgical drainage, which has associated risks of recurrence requiring repeat surgery. Understanding of the underlying pathophysiological processes has been applied to developing potential drug treatments. Ongoing research is needed to identify if these therapies are successful in controlling the inflammatory and angiogenic disease processes leading to control and resolution of CSDH.
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Affiliation(s)
- Ellie Edlmann
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Box 167, Cambridge Biomedical Campus, Cambridge, CB2 0QQ UK
| | - Susan Giorgi-Coll
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Box 167, Cambridge Biomedical Campus, Cambridge, CB2 0QQ UK
| | - Peter C. Whitfield
- Southwest Neurosurgical Centre, Plymouth Hospitals NHS Trust, Plymouth, PL6 8DH UK
| | - Keri L. H. Carpenter
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Box 167, Cambridge Biomedical Campus, Cambridge, CB2 0QQ UK
| | - Peter J. Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Box 167, Cambridge Biomedical Campus, Cambridge, CB2 0QQ UK
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Soleman J, Nocera F, Mariani L. The conservative and pharmacological management of chronic subdural haematoma: a systematic review. Swiss Med Wkly 2017; 147:w14398. [DOI: 10.57187/smw.2017.14398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Chronic subdural haematoma (cSDH), one of the most common neurosurgical entities, occurs typically in elderly patients. The incidence is expected to double by the year 2030, owing to the continuous aging of the population. Surgery is usually the treatment of choice, but conservative treatment may be a good alternative in some situations. We provide a systematic review of studies analysing the conservative treatment options and the natural history of cSDH. Of 231 articles screened, 35 were included in this systematic review. Studies evaluating the natural history and conservative treatment modalities of cSDH remain sparse and are predominantly of low level of evidence. The natural history of cSDH remains unclear and is analysed only in case reports or very small case series. “Wait and watch” or “wait and scan” management is indicated in patients with no or minor symptoms (Markwalder score 0–1). However, it seems that there are no clear clinical or radiological signs indicating whether the cSDH will resolve spontaneously or not (type C recommendation). In symptomatic patients who are not worsening or in a comatose state, oral steroid treatment might be an alternative to surgery (type C recommendation). Tranexamic acid proved effective in a small patient series (type C recommendation), but its risk of increasing thromboembolic events in patients treated with antithrombotic or anticoagulant medication is unclear. Angiotensin converting-enzyme inhibitors were evaluated only as adjuvant therapy to surgery, and their effect on the rate of recurrence remains debatable. Mannitol showed promising results in small retrospective series and might be a valid treatment modality (type C recommendation). However, the long treatment duration is a major drawback. Patients presenting without paresis can be treated with a platelet activating factor receptor antagonist (type C recommendation), since they seem to promote resolution of the haematoma, especially in patients with hygromas or low-density haematomas on computed tomography. Lastly, atorvastatin seems to be a safe option for the conservative treatment of asymptomatic or mildly symptomatic cSDH patients (type C recommendation). In conclusion, our knowledge of the conservative treatment modalities for cSDH is sparse and based on small case series and low grade evidence. However, some treatment modalities seem promising even in symptomatic patients with large haematomas. Randomised controlled trials are currently underway, and will hopefully provide us with good evidence for or against the conservative treatment of cSDH.
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Avanali R, Bhadran B, Krishna Kumar P, Vijayan A, Arun S, Musthafa AM, Panchal S, Gopal VV. Chronic Subdural Hematoma: A Questionnaire Survey of Management Practice in India and Review of Literature. World Neurosurg 2016; 96:355-361. [DOI: 10.1016/j.wneu.2016.09.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 09/05/2016] [Accepted: 09/06/2016] [Indexed: 12/01/2022]
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Kutty RK, Peethambaran AK, Sunilkumar, Anilkumar M. Conservative Treatment of Chronic Subdural Hematoma in HIV-Associated Thrombocytopenia with Tranexamic Acid. J Int Assoc Provid AIDS Care 2016; 16:211-214. [PMID: 27909114 DOI: 10.1177/2325957416680294] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Chronic subdural hematomas (CSDHs) and its management comprise a majority work in a neurosurgical specialty. The effectiveness of surgery is beyond doubt and sometimes even lifesaving in severe cases. However, the straightforward surgery is sometimes complicated by the associated comorbidities of the patient. Comorbidities in the form of coagulopathies secondary to chronic liver diseases, drugs (warfarin, ecosprin, clopidogrel), thrombocytopenia secondary to systemic illness are always a challenge to deal with in patients with CSDH. The authors encountered a patient with thrombocytopenia secondary to systemic HIV infection who presented with CSDH. Her coagulation profile was severe enough to preclude surgery. She was managed conservatively with tranexamic acid and responded well. The authors present the challenges they faced in the course of successful management of this patient.
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Affiliation(s)
- Raja K Kutty
- 1 Department of Neurosurgery, Government Medical College, Trivandrum, Kerala, India
| | | | - Sunilkumar
- 1 Department of Neurosurgery, Government Medical College, Trivandrum, Kerala, India
| | - M Anilkumar
- 1 Department of Neurosurgery, Government Medical College, Trivandrum, Kerala, India
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Law ZK, Meretoja A, Engelter ST, Christensen H, Muresan EM, Glad SB, Liu L, Bath PM, Sprigg N. Treatment of intracerebral haemorrhage with tranexamic acid - A review of current evidence and ongoing trials. Eur Stroke J 2016; 2:13-22. [PMID: 31008298 DOI: 10.1177/2396987316676610] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 09/29/2016] [Indexed: 12/26/2022] Open
Abstract
Purpose Haematoma expansion is a devastating complication of intracerebral haemorrhage (ICH) with no established treatment. Tranexamic acid had been an effective haemostatic agent in reducing post-operative and traumatic bleeding. We review current evidence examining the efficacy of tranexamic acid in improving clinical outcome after ICH. Method We searched MEDLINE, EMBASE, CENTRAL and clinical trial registers for studies using search strategies incorporating the terms 'intracerebral haemorrhage', 'tranexamic acid' and 'antifibrinolytic'. Authors of ongoing clinical trials were contacted for further details. Findings We screened 268 publications and retrieved 17 articles after screening. Unpublished information from three ongoing clinical trials was obtained. We found five completed studies. Of these, two randomised controlled trials (RCTs) comparing intravenous tranexamic acid to placebo (n = 54) reported no significant difference in death or dependency. Three observational studies (n = 281) suggested less haematoma growth with rapid tranexamic acid infusion. There are six ongoing RCTs (n = 3089) with different clinical exclusions, imaging selection criteria (spot sign and haematoma volume), time window for recruitment and dosing of tranexamic acid. Discussion Despite their heterogeneity, the ongoing trials will provide key evidence on the effects of tranexamic acid on ICH. There are uncertainties of whether patients with negative spot sign, large haematoma, intraventricular haemorrhage, or poor Glasgow Coma Scale should be recruited. The time window for optimal effect of haemostatic therapy in ICH is yet to be established. Conclusion Tranexamic acid is a promising haemostatic agent for ICH. We await the results of the trials before definite conclusions can be drawn.
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Affiliation(s)
- Zhe Kang Law
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, UK.,Department of Medicine, Faculty of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia
| | - Atte Meretoja
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland.,Department of Medicine at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Stefan T Engelter
- Stroke Center and Neurology, University Hospital Basel, Basel, Switzerland.,Neurorehabilitation Unit, University of Basel, Basel, Switzerland.,University Center for Medicine of Aging, Felix Platter Hospital, Basel, Switzerland
| | - Hanne Christensen
- Department of Neurology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Eugenia-Maria Muresan
- Emergency Clinical County Hospital Cluj-Napoca, Cluj-Napoca, Romania.,Department of Emergency Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Solveig B Glad
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | - Liping Liu
- Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, UK
| | - Nikola Sprigg
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, UK
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