Expert consensus on drug treatment of chronic subdural hematoma

Establishment and validation of a CT-based prediction model for the good dissolution of mild chronic subdural hematoma with atorvastatin treatment

PURPOSE

To develop and validate a prediction model based on imaging data for the prognosis of mild chronic subdural hematoma undergoing atorvastatin treatment.

METHODS

We developed the prediction model utilizing data from patients diagnosed with CSDH between February 2019 and November 2021. Demographic characteristics, medical history, and hematoma characteristics in non-contrast computed tomography (NCCT) were extracted upon admission to the hospital. To reduce data dimensionality, a backward stepwise regression model was implemented to build a prognostic prediction model. We calculated the area under the receiver operating characteristic curve (AUC) of the prognostic prediction model by a tenfold cross-validation procedure.

RESULTS

Maximum thickness, volume, mean density, morphology, and kurtosis of the hematoma were identified as the most significant predictors of good hematoma dissolution in mild CSDH patients undergoing atorvastatin treatment. The prediction model exhibited good discrimination, with an area under the curve (AUC) of 0.82 (95% confidence interval [CI], 0.74-0.90) and good calibration (p = 0.613). The validation analysis showed the AUC of the final prognostic prediction model is 0.80 (95% CI 0.71-0.86) and it has good prediction performance.

CONCLUSION

The imaging data-based prediction model has demonstrated great prediction accuracy for good hematoma dissolution in mild CSDH patients undergoing atorvastatin treatment. The study results emphasize the importance of imaging data evaluation in the management of CSDH patients.

Investigation of the Efficacy of Bevacizumab Treatment in An Experimental Rat Model of Chronic Subdural Hematoma

INTRODUCTION

Chronic subdural hematoma (cSDH), a condition that develops over time, is characterized by inflammation, angiogenesis, and membrane development. As the population's average age increases, the incidence of cSDH is expected to grow. While surgery is the primary treatment technique, medicinal therapy options are being explored for high-risk patients. Currently, the most effective therapy combination is dexamethasone (Dex) and atorvastatin (Ato); however, it is associated with an increased risk of mortality. This study explored the effects of bevacizumab (Bev), a vascular endothelial growth factor antagonist, on cSDH.

MATERIALS AND METHODS

Ninety-five rats were divided into four groups (n = 18): sham, control hematoma, Dex-Ato, and Bev. Two separate autologous blood injections into the subdural space were used as the model. Weight was monitored for all rats to assess changes in their overall health. The control group was given i.p. saline, the Dex-Ato treatment was given by gavage, and the Bev treatment was given i.p. On seventh, 14th and 21st days six rats from each group were sacrificed and analyzed, while 23 rats were excluded from the experiment.

RESULTS

The maximum immunological response to cSDH was observed on day 14. Hematoma volume decreased over time in all groups. Dex-Ato and Bev were both found effective, while Dex-Ato caused weight loss.

CONCLUSION

Bev had similar effects to the Dex-Ato group and was well tolerated by rats. Given that cSDH is a disease of the elderly and vulnerable populations, Bev may be a viable alternative that can shed light on the disease's etiology for future research.

Development and internal validation of a nomogram to predict temporary acute agitated delirium after surgery for chronic subdural hematoma in elderly patients: an analysis of the clinical database

Background

This study aimed to develop a nomogram for predicting temporary acute agitated delirium after surgery in patients with chronic subdural hematoma (CSH) without neurological compromise and hospitalized in the neurosurgery.

Methods

We included 289 patients with chronic subdural hematoma (CSH) from the medical information system of Yuebei People's Hospital of Shaoguan City, Guangdong Province, and collected 16 clinical indicators within 24 h of admission. We used the least absolute shrinkage and selection operator (LASSO) regression to identify risk factors. We established a multivariate logistic regression model and constructed a nomogram. We performed internal validation by 1,000 bootstrap samples; we plotted a receiver operating curve (ROC) and calculated the area under the curve (AUC), sensitivity, and specificity. We also evaluated the calibration of our model by the calibration curve and the Hosmer-Lemeshow goodness-of-fit test (HL test). We performed a decision curve analysis (DCA) and a clinical impact curve (CIC) to assess the net clinical benefit of our model.

Results

The nomogram included alcoholism history, hepatic insufficiency, verbal rating scale for postoperative pain (VRS), pre-hospital modified Rankin Scale (mRS), and preoperative hematoma thickness as predictors. Our model showed satisfactory diagnostic performance with an AUC value of 0.8474 in the validation set. The calibration curve and the HL test showed good agreement between predicted and observed outcomes (p = 0.9288). The DCA and CIC showed that our model had a high predictive ability for the occurrence of postoperative delirium in patients with CSDH.

Conclusion

We identified alcoholism, liver dysfunction, pre-hospital mRS, preoperative hematoma thickness, and postoperative VRS pain as predictors of postoperative delirium in chronic subdural hematoma patients. We developed and validated a multivariate logistic regression model and a nomogram.

Effectiveness of tranexamic acid on chronic subdural hematoma recurrence: a meta-analysis and systematic review

Objectives

Our objective was to compare the effectiveness of TXA in improving recurrence in patients with chronic subdural hematoma (CSDH).

Methods

Eligible randomized controlled trials (RCTs), prospective trials and retrospective cohort studies were searched in PubMed, Cochrane Library, Embase, and CNKI from database inception to December 2023. After the available studies following inclusion and exclusion criteria were screened, the main outcome measures were strictly extracted. Reman v5.4. was used to assess the overall recurrence rate. A random-effects model was used to assess pooled ORs, with the Mantel-Haenszel estimation method applied. Cochran Q (Chi-square) test and I2 statistics were used to assess inter-study heterogeneity. Funnel plots were used to evaluate publication bias.

Results

From the 141 articles found during initial citation screening, 9 literatures were ultimately included in our study. Our NMA results illustrated that patients with newly diagnosed Chronic subdural hematoma revealed a significantly improved recurrence rate when patients were treated with Tranexamic acid (OR: 0.33; 95% CI 0.26-0.41; p < 0.00001) compared with standard neurosurgical treatment. There was no significant difference in the incidence rates of thrombosis (OR: 0.84; 95% CI 0.63-1.12; p = 0.23) and mortality (OR: 1.0; 95% CI 0.57-11.76; p = 0.99), Occurrence of myocardial infarction was significantly less frequent in TXA users than in nonusers (OR: 0.18; 95% CI 0.04-0.82; p = 0.03).

Conclusion

TXA can effectively improve the recurrence rate of CDSH. It provides a high level of evidence-based medicine for clinical treatment. In addition, multicenter randomized controlled trials, with dose adjustments, are still needed to determine whether TXA intervention improves neurological function or prognosis.

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

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

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

PURPOSE OF REVIEW

Chronic subdural hematoma (cSDH) is a common intracranial hemorrhagic disorder with a high incidence rate among the elderly. While small, asymptomatic cSDH may resolve spontaneously, surgical intervention has been the treatment of choice for larger, symptomatic cases. Surgical evacuation of cSDH may be associated with high rates of recurrence, and even asymptomatic cSDH cases tend to progress. Over the last few years, middle meningeal artery (MMA) embolization has proven to be a safe non-invasive treatment of choice with favorable outcomes and a low recurrence rate. The ensuing paper discusses current treatment modalities for cSDH and reviews existing literature on the anatomy of MMA and its embolization as a treatment option for cSDH.

RECENT FINDINGS

Recent studies show that traumatic head injury leading to subdural hemorrhage can induce neovascularization that may initiate a cycle of recurrent subdural hematoma. Distal branches of MMA supply blood to the dural layers. Several studies have revealed that embolization of the MMA can stop the neovascularization process and blood flow. In addition, patients who underwent MMA embolization had a significantly quicker brain re-expansion and lower recurrence rate. Although the management of cSDH is still very much a dilemma, recent research findings bring MMA embolization to light as a promising treatment alternative and adjunctive therapy.

A bibliometric analysis of chronic subdural hematoma since the twenty-first century

BACKGROUND

Chronic subdural hematoma (CSDH) is a common disease that forms between the dura and arachnoid membranes of the brain. With the development of medications and surgery, significant progress has been made in the diagnosis and treatment of CSDH. However, there is no comprehensive analysis available on CSDH-related studies published in the literature. This study aimed to collect and analyze CSDH-related studies published since the twenty-first century using bibliometric analysis and to summarize the current status of research in this field for the sake of providing systematic data for further study of CSDH.

METHODS

CSDH-related studies were searched in the Web of Science Core Collection (WoSCC) database using the Medical Subject Heading (MeSH) term 'chronic subdural hematoma'. Data analysis and visualization were performed by R and CiteSpace software.

RESULTS

This study retrieved 1424 CSDH-related articles published since the beginning of the twenty-first century. There was a general increase in both the number of published articles and the mean number of citations. The authors, institutions and journals that contributed the most to the field of CSDH were Jianning Zhang, Tianjin Medical University, and world neurosurgery, respectively. The reference co-citation network identified 13 clusters with significant modularity Q scores and silhouette scores (Q = 0.7124, S = 0.8536). The major research categories were (1) evolution of the therapeutic method and (2) the etiology and pathology of CSDH. Keyword analysis revealed that 'middle meningeal artery embolization' was the latest burst keyword.

CONCLUSIONS

This study identified the most influential countries, authors, institutions and journals contributing to CSDH research and discussed the hotspots and the latest subjects of CSDH research.

Effectiveness Comparisons of Drug Therapy on Chronic Subdural Hematoma Recurrence: A Bayesian Network Meta-Analysis and Systematic Review

Objectives: We aim to compare the effectiveness of different drug treatments in improving recurrence in patients with chronic subdural hematoma (CSDH).

Methods: Eligible randomized controlled trials (RCTs) and prospective trials were searched in PubMed, Cochrane Library, and Embase, from database inception to December 2021. After the available studies following inclusion and exclusion criteria were screened, the main outcome measures were strictly extracted. Taking the random-effects model, dichotomous data were determined and extracted by odds ratio (OR) with 95% credible interval (CrI), and a surface under the cumulative ranking curve (SUCRA) was generated to calculate the ranking probability of comparative effectiveness among each drug intervention. Moreover, we used the node-splitting model to evaluate inconsistency between direct and indirect comparisons of our network meta-analysis (NMA). Funnel plots were used to evaluate publication bias.

Results: From the 318 articles found during initial citation screening, 11 RCTs and 3 prospective trials (n = 3,456 participants) were ultimately included in our study. Our NMA results illustrated that atorvastatin + dexamethasone (ATO+DXM) (OR = 0.06, 95% CrI 0.01, 0.89) was the most effective intervention to improve recurrence in patients with CSDH (SUCRA = 89.40%, 95% CrI 0.29, 1.00). Four drug interventions [ATO+DXM (OR = 0.06, 95% CrI 0.01, 0.89), DXM (OR = 0.18, 95% CrI 0.07, 0.41), tranexamic acid (TXA) (OR = 0.26, 95% CrI 0.07, 0.41), and ATO (OR = 0.41, 95% CrI 0.12, 0.90)] achieved statistical significance in improving recurrence in CSDH patients compared with the placebo (PLB) or standard neurosurgical treatment (SNT) group.

Conclusion: Our NMA showed that ATO+DXM, DXM, ATO, and TXA had definite efficacy in improving recurrence in CSDH patients. Among them, ATO+DXM is the best intervention for improving recurrence in patients with CSDH in this particular population. Multicenter rigorous designed prospective randomized trials are still needed to evaluate the role of various drug interventions in improving neurological function or outcome.

Systematic Review Registration: (https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=299491), identifier (CRD 42022299491).