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Kinoshita S, Ohkuma H, Fujiwara N, Katayama K, Naraoka M, Shimamura N, Tabata H, Takemura A, Hasegawa S, Saito A. Long-term postoperative prognosis and associated risk factors of chronic subdural hematoma in the elderly. Clin Neurol Neurosurg 2024; 243:108186. [PMID: 38936175 DOI: 10.1016/j.clineuro.2024.108186] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 02/15/2024] [Accepted: 02/18/2024] [Indexed: 06/29/2024]
Abstract
Surgical treatment for chronic subdural hematoma(CSDH)has contributed to good outcome. However, several recent studies have revealed that surgical outcomes for elderly patients were not decisively good. In this study, prognosis of CSDH patients in elderly were analyzed. This study included 232 CSDH patients who were treated in our department and 2 affiliated hospitals, and poor prognosis was defined as aggravation of modified Rankin scale (mRS) at examination comparing with that at discharge, or mRS 3 and higher at examination. We collected data from medical records and questionnaires on the following clinical characteristics of patients: age, sex, findings at admission, medication of antiplatelets and anticoagulants, radiological findings on computed tomography, recurrence, place of discharge, perioperative systemic complications, and mRS at discharge and at examination. The cut-off value of age for poor prognosis of all CSDH patients was 74 years old in this study. In multivariate analysis of all cases, age was prognostic factor for poor outcome:75 years old or higher(p=0.0002). In this group, mRS at discharge(p=0.0184) and postoperative medical diseases(p<0.0001) were the risk factors of poor prognosis. In this present study, high age and activities of daily life(ADL) at discharge were significant prognostic factors for poor outcome of CSDH. Improvement of ADL at discharge with care for postoperative systemic complications and careful rehabilitation can contribute to good prognosis for CSDH in elderly patients.
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Affiliation(s)
- Shohei Kinoshita
- Department of Neurosurgery, Hirosaki University Hospital, Hirosaki, Aomori, Japan
| | - Hiroki Ohkuma
- Department of Neurosurgery, NHO, Hirosaki General Medical Center, Hirosaki, Aomori, Japan.
| | - Nozomi Fujiwara
- Department of Neurosurgery, Hirosaki University Hospital, Hirosaki, Aomori, Japan
| | - Kosuke Katayama
- Department of Neurosurgery, Kuroishi General Hospital, Kuroishi, Aomori, Japan
| | - Masato Naraoka
- Department of Advanced Emergency And Disaster Medical Center, Hirosaki University Hospital, Hirosaki, Aomori, Japan
| | - Norihito Shimamura
- Department of Neurosurgery, NHO, Hirosaki General Medical Center, Hirosaki, Aomori, Japan
| | - Hidefumi Tabata
- Department of Neurosurgery, Aomori City Hospital, Aomori, Aomori, Japan
| | - Atsuhito Takemura
- Department of Neurosurgery, Southern Tohoku Hospital, Iwanuma, Miyagi, Japan
| | - Seiko Hasegawa
- Department of Advanced Emergency And Disaster Medical Center, Hirosaki University Hospital, Hirosaki, Aomori, Japan
| | - Atsushi Saito
- Department of Neurosurgery, Hirosaki University Hospital, Hirosaki, Aomori, Japan
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Zhong D, Cheng H, Xian Z, Ren Y, Li H, Ou X, Liu P. Advances in pathogenic mechanisms, diagnostic methods, surgical and non-surgical treatment, and potential recurrence factors of Chronic Subdural Hematoma: A review. Clin Neurol Neurosurg 2024; 242:108323. [PMID: 38749358 DOI: 10.1016/j.clineuro.2024.108323] [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: 02/29/2024] [Revised: 05/05/2024] [Accepted: 05/06/2024] [Indexed: 06/16/2024]
Abstract
Chronic Subdural Hematoma (CSDH) is a common hemorrhagic disease in neurosurgery, and with the intensification of global aging, its incidence is gradually increasing. With the advancement of scientific technology, the etiological concepts and surgical treatments for CSDH have continually evolved over time. Currently, neuroscientists' understanding of CSDH is no longer confined to bridging vein rupture; exploration of various mechanisms such as angiogenesis, maturation of blood vessels, and inflammation is also underway. In-depth exploration and discovery of pathogenic mechanisms guide the updating of clinical treatment strategies and methods. For different types of CSDH, there is now a clear guidance for the targeted selection of treatment methods. However, the current treatment of CSDH cannot completely solve all problems, and the updating of treatment methods as well as the development and validation of new effective drugs remain challenges for the future. In addition, the recurrence of CSDH is a significant issue that needs to be addressed. Although we have reviewed potential recurrent factors that may be associated, the strength of this evidence is insufficient. Future research should gradually focus on validating these recurrent factors and exploring new ones, in order to optimize the existing understanding and treatment of CSDH.
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Affiliation(s)
- Dayuan Zhong
- Nanhai hospital of Traditional Chinese Medicine, Jinan University, Foshan 528200, China; Neurosurgery, Guangdong Hospital of Integrated Traditional Chinese and Western Medicine, Foshan 528200, China
| | - Hui Cheng
- Nanhai hospital of Traditional Chinese Medicine, Jinan University, Foshan 528200, China; Neurosurgery, Guangdong Hospital of Integrated Traditional Chinese and Western Medicine, Foshan 528200, China
| | - Zhuoyan Xian
- Nanhai hospital of Traditional Chinese Medicine, Jinan University, Foshan 528200, China
| | - Yanhai Ren
- Nanhai hospital of Traditional Chinese Medicine, Jinan University, Foshan 528200, China; Neurosurgery, Guangdong Hospital of Integrated Traditional Chinese and Western Medicine, Foshan 528200, China
| | - Huanjie Li
- Department of Preventive Medicine, Foshan Hospital of Traditional Chinese Medicine, Foshan 528051, China.
| | - Xueming Ou
- Nanhai hospital of Traditional Chinese Medicine, Jinan University, Foshan 528200, China; Neurosurgery, Guangdong Hospital of Integrated Traditional Chinese and Western Medicine, Foshan 528200, China.
| | - Pingwen Liu
- Nanhai hospital of Traditional Chinese Medicine, Jinan University, Foshan 528200, China; Neurosurgery, Guangdong Hospital of Integrated Traditional Chinese and Western Medicine, Foshan 528200, China.
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3
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Sun T, Shao D, Li J, Xu D, Zhang T, Li L, Sun W, Zhang C, Wen X, Chen H, Zhang R, Jiang Z. Therapeutic efficacy of drilling drainage combined with intraoperative middle meningeal artery occlusion in the management of chronic subdural hematoma: a clinical study. Neurosurg Rev 2024; 47:293. [PMID: 38914867 PMCID: PMC11196335 DOI: 10.1007/s10143-024-02501-1] [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: 04/04/2024] [Revised: 05/27/2024] [Accepted: 06/04/2024] [Indexed: 06/26/2024]
Abstract
BACKGROUND The bone holes in the skull during surgical drainage were accurately located at the site of the MMA. The MMA was severed, and the hematoma was removed intraoperatively; furthermore, surgical drainage removed the pathogenic factors of CSDH. This study aimed to describe and compare the results of the new treatment with those of traditional surgical drainage, and to investigate the relevance of this approach. METHODS From December 2021 to June 2023, 72 patients were randomly assigned to the observation group and the control group. The control group was treated with traditional surgical drainage, while the observation group was treated with DSA imaging to accurately locate the bone holes drilled in the skull on the MMA trunk before traditional surgical drainage. The MMA trunk was severed during the surgical drainage of the hematoma. The recurrence rate, time of indwelling drainage tube, complications, mRS, and other indicators of the two groups were compared, and the changes of cytokine components and imaging characteristics of the patients were collected and analyzed. RESULTS Overall, 27 patients with 29-side hematoma in the observation group and 45 patients with 48-side hematoma in the control group were included in the study. The recurrence rate was 0/29 in the observation group and 4/48 in the control group, indicating that the recurrence rate in the observation group was lower than in the control group (P = .048). The mean indwelling time of the drainage tube in the observation group was 2.04 ± 0.61 days, and that in the control group was 2.48 ± 0.61 days. The indwelling time of the drainage tube in the observation group was shorter than in the control group (P = .003). No surgical complications were observed in the observation group or the control group. The differences in mRS scores before and after operation between the observation group and the control group were statistically significant (P < .001). The concentrations of cytokine IL6/IL8/IL10/VEGF in the hematoma fluid of the observation and control groups were significantly higher than those in venous blood (P < .001). After intraoperative irrigation and drainage, the concentrations of cytokines (IL6/IL8/IL10/VEGF) in the subdural hematoma fluid were significantly lower than they were preoperatively. In the observation group, the number of MMA on the hematoma side (11/29) before STA development was higher than that on the non-hematoma side (1/25), and the difference was statistically significant (P = .003). CONCLUSION In patients with CSDH, accurately locating the MMA during surgical trepanation and drainage, severing the MMA during drainage, and properly draining the hematoma, can reduce the recurrence rate and retention time of drainage tubes, thereby significantly improving the postoperative mRS Score without increasing surgical complications.
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Affiliation(s)
- Tao Sun
- School of Continuing Education, Anhui Medical University, Hefei, China
- Department of Neurosurgery, The First Affiliated Hospital of Bengbu Medical University, Bengbu, China
| | - Dongqi Shao
- Department of Neurosurgery, The First Affiliated Hospital of Bengbu Medical University, Bengbu, China
| | - Jian Li
- Department of Neurosurgery, The First Affiliated Hospital of Bengbu Medical University, Bengbu, China
| | - Decai Xu
- Department of Neurosurgery, The First Affiliated Hospital of Bengbu Medical University, Bengbu, China
| | - Tao Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Bengbu Medical University, Bengbu, China
| | - Lei Li
- Department of Neurosurgery, The First Affiliated Hospital of Bengbu Medical University, Bengbu, China
| | - Wenjie Sun
- Department of Neurosurgery, The First Affiliated Hospital of Bengbu Medical University, Bengbu, China
| | - Caihong Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Bengbu Medical University, Bengbu, China
| | - Xinjie Wen
- Department of Neurosurgery, The First Affiliated Hospital of Bengbu Medical University, Bengbu, China
| | - Haonan Chen
- Department of Neurosurgery, The First Affiliated Hospital of Bengbu Medical University, Bengbu, China
| | - Renhao Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Bengbu Medical University, Bengbu, China
| | - Zhiquan Jiang
- School of Continuing Education, Anhui Medical University, Hefei, China.
- Department of Neurosurgery, The First Affiliated Hospital of Bengbu Medical University, Bengbu, China.
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Salah WK, Findlay MC, Baker CM, Scoville JP, Bounajem MT, Ogilvy CS, Moore JM, Riina HA, Levy EI, Siddiqui AH, Spiotta AM, Cawley CM, Khalessi AA, Tanweer O, Hanel R, Gross BA, Kuybu O, Howard BM, Hoang AN, Baig AA, Khorasanizadeh M, Mendez Ruiz AA, Cortez G, Davies JM, Lang MJ, Thomas AJ, Tonetti DA, Khalife J, Sioutas GS, Carroll K, Abecassis ZA, Jankowitz BT, Ruiz Rodriguez J, Levitt MR, Kan PT, Burkhardt JK, Srinivasan V, Salem MM, Grandhi R. The Influence of Coagulopathy on Radiographic and Clinical Outcomes in Patients Undergoing Middle Meningeal Artery Embolization as Standalone Treatment for Non-acute Subdural Hematomas. J Neurotrauma 2024; 41:1375-1383. [PMID: 38481125 DOI: 10.1089/neu.2023.0413] [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] [Indexed: 04/11/2024] Open
Abstract
Middle meningeal artery embolization (MMAE) is emerging as a safe and effective standalone intervention for non-acute subdural hematomas (NASHs); however, the risk of hematoma recurrence after MMAE in coagulopathic patients is unclear. To characterize the impact of coagulopathy on treatment outcomes, we analyzed a multi-institutional database of patients who underwent standalone MMAE as treatment for NASH. We classified 537 patients who underwent MMAE as a standalone intervention between 2019 and 2023 by coagulopathy status. Coagulopathy was defined as use of anticoagulation/antiplatelet agents or pre-operative thrombocytopenia (platelets <100,000/μL). Demographics, pre-procedural characteristics, in-hospital course, and patient outcomes were collected. Thrombocytopenia, aspirin use, antiplatelet agent use, and anticoagulant use were assessed using univariate and multivariate analyses to identify any characteristics associated with the need for rescue surgical intervention, mortality, adverse events, and modified Rankin Scale score at 90-day follow-up. Propensity score-matched cohorts by coagulopathy status with matching covariates adjusting for risk factors implicated in surgical recurrence were evaluated by univariate and multivariate analyses. Minimal differences in pre-operative characteristics between patients with and those without coagulopathy were observed. On unmatched and matched analyses, patients with coagulopathy had higher rates of requiring subsequent surgery than those without (unmatched: 9.9% vs. 4.3%; matched: 12.6% vs. 4.6%; both p < 0.05). On matched multivariable analysis, patients with coagulopathy had an increased odds ratio (OR) of requiring surgical rescue (OR 3.95; 95% confidence interval [CI] 1.68-9.30; p < 0.01). Antiplatelet agent use (ticagrelor, prasugrel, or clopidogrel) was also predictive of surgical rescue (OR 4.38; 95% CI 1.51-12.72; p = 0.01), and patients with thrombocytopenia had significantly increased odds of in-hospital mortality (OR 5.16; 95% CI 2.38-11.20; p < 0.01). There were no differences in follow-up radiographic and other clinical outcomes in patients with and those without coagulopathy. Patients with coagulopathy undergoing standalone MMAE for treatment of NASH may have greater risk of requiring surgical rescue (particularly in patients using antiplatelet agents), and in-hospital mortality (in thrombocytopenic patients).
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Affiliation(s)
- Walid K Salah
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
- School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | | | - Cordell M Baker
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Jonathan P Scoville
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Michael T Bounajem
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Christopher S Ogilvy
- Department of Neurological Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Justin M Moore
- Department of Neurological Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Howard A Riina
- Department of Neurosurgery, NYU Langone Health, New York, New York, USA
| | - Elad I Levy
- Department of Neurosurgery, University at Buffalo, Buffalo, New York, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, University at Buffalo, Buffalo, New York, USA
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - C Michael Cawley
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Alexander A Khalessi
- Department of Neurological Surgery, University of California San Diego, La Jolla, California, USA
| | - Omar Tanweer
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Ricardo Hanel
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA
| | - Bradley A Gross
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Okkes Kuybu
- Department of Neurosurgery, Penn Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Brian M Howard
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Alex N Hoang
- Department of Neurosurgery, Houston Methodist, Houston, Texas, USA
| | - Ammad A Baig
- Department of Neurosurgery, University at Buffalo, Buffalo, New York, USA
| | | | - Aldo A Mendez Ruiz
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Gustavo Cortez
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA
| | - Jason M Davies
- Department of Neurosurgery, University at Buffalo, Buffalo, New York, USA
| | - Michael J Lang
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ajith J Thomas
- Department of Neurosurgery, Cooper University Healthcare, Camden, New Jersey, USA
| | - Daniel A Tonetti
- Department of Neurosurgery, Cooper University Healthcare, Camden, New Jersey, USA
| | - Jane Khalife
- Department of Neurosurgery, Cooper University Healthcare, Camden, New Jersey, USA
| | - Georgios S Sioutas
- Department of Neurosurgery, Penn Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kate Carroll
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Zachary A Abecassis
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Brian T Jankowitz
- Department of Neurosurgery, Penn Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Juan Ruiz Rodriguez
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Michael R Levitt
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Peter T Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Penn Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Visish Srinivasan
- Department of Neurosurgery, Penn Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mohamed M Salem
- Department of Neurosurgery, Penn Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ramesh Grandhi
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
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5
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Mathew C, Wong TGL, Leong RWL. Local anesthesia versus general anesthesia for surgical drainage of chronic subdural hematoma: a systematic review and meta-analysis. Can J Anaesth 2024; 71:870-882. [PMID: 38418762 DOI: 10.1007/s12630-024-02703-7] [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: 07/26/2023] [Revised: 11/20/2023] [Accepted: 11/21/2023] [Indexed: 03/02/2024] Open
Abstract
PURPOSE The optimal anesthetic technique for surgical drainage of chronic subdural hematoma (CSDH) is still uncertain. We performed this systematic review and meta-analysis to determine if local anesthesia with or without sedation (LA) or general anesthesia (GA) results in better outcomes for surgical drainage of CSDH. METHODS We searched PubMed, EMBASE, Scopus, Cochrane Central Register of Controlled Trials and ClinicalTrials.gov for randomized controlled trials (RCTs) and prospective or retrospective studies that compared GA vs LA for adult patients undergoing surgical drainage of CSDH and reported at least one outcome of interest. Primary outcomes of interest included total duration of surgery, recurrence rate, and length of hospital stay (LOS). Secondary outcomes included intraoperative adverse events, postoperative complications, and postoperative mortality. RESULTS Eight studies (1,542 patients; 926 LA; 616 GA) were included-two were RCTs and six were observational studies. Pooling the estimates of all available studies, we found that LA was associated with a decreased mean LOS by about two days (95% confidence interval [CI], -3.47 to -0.77; P = 0.01; low certainty of evidence) as well as a lower risk of postoperative complications (odds ratio, 0.31; 95% CI, 0.17 to 0.58; P = 0.004; very low certainty of evidence). There was no significant difference in terms of duration of surgery, recurrence rate, intraoperative adverse events, or mortality. The quality of the observational studies was poor to fair, largely because of heterogeneity among the studies. Among the RCTs, one had a low risk of bias and one was deemed to be at high risk of bias. CONCLUSIONS Local anesthesia with/without sedation for surgical drainage of CSDH may be associated with a shorter LOS, and lower postoperative complications. As most of our included studies were observational in nature, our results should be interpreted as summaries of unadjusted group comparisons. In view of the low certainty of evidence, higher quality evidence is required to corroborate these findings. STUDY REGISTRATION PROSPERO (CRD42022333388); first submitted 1 June 2022.
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Affiliation(s)
- Christopher Mathew
- Division of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore.
| | - Theodore G L Wong
- Division of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Rachel W L Leong
- Division of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
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Rai AT, Halak AA, Lakhani DA, Tarabishy AR, Siddiqui AH. Population-based estimates suggest middle meningeal artery embolization for subdural hematomas could significantly expand the scope of neurovascular therapies. J Neurointerv Surg 2024:jnis-2024-021686. [PMID: 38604765 DOI: 10.1136/jnis-2024-021686] [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: 03/07/2024] [Accepted: 03/25/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND This study quantifies the impact of middle meningeal artery embolization (MMAE) for subdural hematomas (SDHs) by estimating a target population. METHODS A population-based study at a tertiary hospital, the main SDH facility for a four-county population, used primary ICD-10 codes over 3 years to collate SDH hospitalizations. Clinical and imaging data confirmed traumatic versus non-traumatic and acute versus non-acute (mixed or chronic) SDH. The MMAE-eligible population included patients with non-traumatic, non-acute SDH aged ≥18 years plus patients with 'traumatic' but non-acute SDH aged ≥60 years presenting with a fall. This was contrasted with the rate of large vessel strokes in the same population. RESULTS 1279 hospitalizations with a primary ICD-10 SDH diagnosis were identified, with 389 from the study population. Excluding repeat admissions, 350 patients were analyzed, 233 (67%) traumatic, and 117 (33%) non-traumatic SDH. Regarding etiology, 'fall ≥60 years' was the most common category in the entire cohort (n=156; 45% (95% CI 39% to 50%)). The SDH rate was 52/100 000 persons/year (95% CI 47 to 57). The rate of all non-traumatic, non-acute SDH in patients aged ≥18 years was 17/100 000 persons/year (95% CI 15 to 20), combining with 'traumatic' but non-acute fall-related SDH in patients aged ≥60 years yielded 41/100 000 persons/year (95% CI 36 to 47). This demographic may represent an MMAE-eligible population, exceeding large vessel stroke rates (31/100 000 persons/year) in the same population, estimating 139 387 potential MMAE cases/year (95% CI 121 517 to 158 168) in the USA. CONCLUSION MMAE could transform non-acute SDH management, especially in the elderly, potentially surpassing the impact of large vessel stroke. Clinical trials are essential for validation of its efficacy and safety compared with standard management.
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Affiliation(s)
- Ansaar T Rai
- Interventional Neuroradiology, West Virginia University Rockefeller Neuroscience Institute, Morgantown, West Virginia, USA
| | - Abdulrahman A Halak
- Neuroradiology, West Virginia University Rockefeller Neuroscience Institute, Morgantown, West Virginia, USA
| | - Dhairya A Lakhani
- Neuroradiology, West Virginia University Rockefeller Neuroscience Institute, Morgantown, West Virginia, USA
| | - Abdul R Tarabishy
- Neuroradiology, West Virginia University Rockefeller Neuroscience Institute, Morgantown, West Virginia, USA
| | - Adnan H Siddiqui
- Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
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7
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Brannigan JFM, Gillespie CS, Adegboyega G, Watson M, Lee KS, Mazzoleni A, Goacher E, Mantle O, Omar V, Gamage G, Yanez Touzet A, Mowforth O, Thomas W, Uprichard J, Hutchinson PJ, Stubbs DJ, Davies BM. Impact of antithrombotic agents on outcomes in patients requiring surgery for chronic subdural haematoma: a systematic review and meta-analysis. Br J Neurosurg 2024:1-8. [PMID: 38584489 DOI: 10.1080/02688697.2024.2333399] [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: 12/14/2023] [Accepted: 03/12/2024] [Indexed: 04/09/2024]
Abstract
A chronic subdural haematoma (CSDH) is a collection of aged blood between the dura and the brain, typically treated with surgical evacuation. Many patients with CSDH have comorbidities requiring the use of antithrombotic medications. The optimal management of these medications in the context of CSDH remains unknown, as the risk of recurrence must be carefully weighed against the risk of vaso-occlusive events. To better understand these risks and inform the development of clinical practice guidelines, we conducted a systematic review and meta-analysis. A systematic review was conducted in accordance with the PRISMA guidelines, searching Medline and Embase databases. The study was registered with PROSPERO (CRD42023397061). A total of 44 studies were included, encompassing 1 prospective cohort study and 43 retrospective cohort studies. Pooled odds ratios (ORs) were calculated for CSDH recurrence and vaso-occlusive events in patients taking anticoagulant or antiplatelet medications compared to patients not receiving antithrombotic therapy. GRADE was used to assess the quality of evidence. In patients on anticoagulant therapy at CSDH diagnosis, the pooled OR for CSDH recurrence was 1.41 (95% CI 1.11 to 1.79; I2 = 28%). For patients on antiplatelet therapy, the pooled OR was 1.31 (95% CI 1.08 to 1.58; I2 = 32%). Patients taking antithrombotic medications had a significantly higher risk of vaso-occlusive events, with a pooled OR of 3.74 (95% CI 2.12 to 6.60; I2 = 0%). There was insufficient evidence to assess the impact of time to recommence antithrombotic medication on CSDH outcomes. We found that baseline antithrombotic use is associated with the risk of CSDH recurrence and vaso-occlusive events following surgical evacuation. The evidence base is of low quality, and decisions regarding antithrombotic therapy should be individualised for each patient. Further high-quality, prospective studies or registry-based designs are needed to better inform clinical decision-making and establish evidence-based guidelines.
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Affiliation(s)
- Jamie F M Brannigan
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Conor S Gillespie
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Gideon Adegboyega
- Addenbrookes Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Matthew Watson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | | | - Adele Mazzoleni
- Barts and the London School of Medicine, Queen Mary University of London, London, UK
| | - Edward Goacher
- Sheffield University Teaching Hospitals NHS Trust, Sheffield, UK
| | | | - Vian Omar
- University of Buckingham Medical School, Buckingham, UK
| | - Githmi Gamage
- Royal College of Surgeons of Ireland, Dublin, Republic of Ireland
| | - Alvaro Yanez Touzet
- School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Oliver Mowforth
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Will Thomas
- Department of Haematology, Cambridge University Hospitals NHS Foundation trust, Cambridge, UK
| | - James Uprichard
- Department of Haematology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Daniel J Stubbs
- Department of Haematology, St George's University Hospitals NHS Foundation Trust, London, UK
- Division of Anaesthesia, University of Cambridge Addenbrooke's Hospital Cambridge, Cambridge, UK
| | - Benjamin M Davies
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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8
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Sadasivan C, Dashti N, Marfoglio S, Fiorella D. In vitro comparison of middle meningeal artery embolization with Squid liquid embolic agent and Contour polyvinyl alcohol particles. J Neurointerv Surg 2024; 16:280-284. [PMID: 37142394 DOI: 10.1136/jnis-2023-020132] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 04/24/2023] [Indexed: 05/06/2023]
Abstract
BACKGROUND Liquid embolic agents and polyvinyl alcohol (PVA) particles have been used for the embolization of the middle meningeal artery (MMA) for the treatment of chronic subdural hematomas. However, the vascular penetration and distribution of these embolic agents have not yet been compared. The current study compares distribution of a liquid embolic agent (Squid) to PVA particles (Contour) in an in vitro model of the MMA. METHODS MMA models were embolized with Contour PVA particles 45-150 µm, Contour PVA particles 150-250 µm, and Squid-18 liquid embolic agent (n=5 each). The models were scanned and every vascular segment with embolic agent was manually marked on the images. Embolized vascular length as a percentage of control, average embolized vascular diameter, and embolization time were compared between the groups. RESULTS The 150-250 µm Contour particles primarily accumulated close to the microcatheter tip, yielding proximal branch occlusions. The 45-150 µm Contour particles achieved a more distal distribution, but in a patchy segmental pattern. However, the models embolized with Squid-18 had a consistently distal, near-complete and homogenous distribution. Embolized vascular length was significantly higher (76±13% vs 5±3%, P=0.0007) and average embolized vessel diameter was significantly smaller (405±25 µm vs 775±225 µm, P=0.0006) with Squid than with Contour. Embolization time with Squid was also lower (2.8±2.4 min vs 6.4±2.7 min, P=0.09). CONCLUSIONS Squid-18 liquid results in a considerably more consistent, distal and homogeneous pattern of embolysate distribution than Contour PVA particles in an anatomical model of the MMA tree.
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Affiliation(s)
- Chander Sadasivan
- Department of Neurological Surgery, Stony Brook University, Stony Brook, New York, USA
| | - Nakisa Dashti
- Department of Neurological Surgery, Stony Brook University, Stony Brook, New York, USA
| | - Samantha Marfoglio
- Department of Neurological Surgery, Stony Brook University, Stony Brook, New York, USA
| | - David Fiorella
- Department of Neurological Surgery, Stony Brook University, Stony Brook, New York, USA
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9
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Qiao Y, Zhang YJ, Tsappidi S, Mehta TI, Hui FK. Direct superficial temporal artery access for middle meningeal artery embolization. Interv Neuroradiol 2024:15910199231225832. [PMID: 38196319 DOI: 10.1177/15910199231225832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024] Open
Abstract
Middle meningeal artery embolization has become an important option in the management of subdural hemorrhages with multiple prospective studies demonstrating efficacy and randomized controlled trial data on the way. Access to the middle meningeal artery is usually achieved via the external carotid artery to the internal maxillary artery, then the middle meningeal artery. We report a case where a patient with symptomatic left-sided chronic subdural hemorrhage also had an external carotid artery occlusion. Direct puncture of the superficial temporal artery allowed retrograde access to the internal maxillary artery and thus the middle meningeal artery. Successful embolization of the vessel with 1:9 nBCA was performed with near total resorption of the subdural collection by 1 month postprocedure.
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Affiliation(s)
- Yang Qiao
- Department of Diagnostic and Interventional Imaging, The University of Texas Health Science Center at Houston, Houston, TX, USA
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Department of Neurointerventional Surgery, The Queen's Health System, Honolulu, HI, USA
| | - Yi Jonathan Zhang
- Department of Neurointerventional Surgery, The Queen's Health System, Honolulu, HI, USA
| | - Samuel Tsappidi
- Department of Neurointerventional Surgery, The Queen's Health System, Honolulu, HI, USA
| | - Tej I Mehta
- Department of Radiology and Radiological Science, Johns Hopkins Medicine, Baltimore, MD, USA
| | - Ferdinand K Hui
- Department of Neurointerventional Surgery, The Queen's Health System, Honolulu, HI, USA
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10
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Yang C, Lin G, Zhang J, Xie J, Yang J. Granuloma formation as a late complication of burr-hole surgery for chronic subdural hematoma. Brain Inj 2024; 38:3-6. [PMID: 38225760 DOI: 10.1080/02699052.2024.2304860] [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: 12/29/2021] [Accepted: 01/09/2024] [Indexed: 01/17/2024]
Abstract
BACKGROUND Surgical treatment remains the mainstream therapeutic regimen for chronic subdural hematoma (CSDH), and burr-hole craniostomy with subdural drainage is the preferable approach. Herein, we reported a case of intracranial granuloma formation as a late complication of burr-hole surgery for CSDH. CASE PRESENTATION A 31-year-old man presented with a 1-month history of headache. Head computed tomography (CT) showed a subdural hematoma in the left frontal-temporal-parietal region with significant midline shifting. A burr-hole evacuation of the hematoma with closed-system drainage was performed. CT obtained immediately after the surgery demonstrated that the hematoma was mostly evacuated. Nine months later, he presented to us again due to intermittent headache in the left temporoparietal region. Brain magnetic resonance imaging revealed a space-occupying mass at the site of the original hematoma. A bone-flap craniotomy was performed for resecting the mass. Histopathological examination revealed a granuloma. The microbial cultivation of the resected specimen was negative. The postoperative course was uneventful, and the headache was relieved. CONCLUSION Granuloma formation is an extremely rare late complication of burr-hole surgery for CSDH. Physicians involved in the perioperative management of CSDH should be aware of this condition, and bone-flap craniotomy may be warranted.
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Affiliation(s)
- Chenlong Yang
- Department of Neurosurgery, Peking University Third Hospital, Beijing, China
| | - Guozhong Lin
- Department of Neurosurgery, Peking University Third Hospital, Beijing, China
| | | | - Jingcheng Xie
- Department of Neurosurgery, Peking University Third Hospital, Beijing, China
| | - Jun Yang
- Department of Neurosurgery, Peking University Third Hospital, Beijing, China
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11
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Wang B, Li K, Guo C, Wang Z, Zhu W, Lu C. Evaluation of Effectiveness of Atorvastatin in Treating Chronic Subdural Hematoma not Requiring Surgery: A Meta-Analysis of Randomized Controlled Trials. Ann Indian Acad Neurol 2024; 27:19-26. [PMID: 38495243 PMCID: PMC10941892 DOI: 10.4103/aian.aian_818_23] [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: 09/13/2023] [Revised: 12/14/2023] [Accepted: 12/17/2023] [Indexed: 03/19/2024] Open
Abstract
Chronic subdural hematoma (CSDH) is a chronic space-occupying lesion formed by blood accumulation between the arachnoid membrane and the dura mater. Atorvastatin is of increasing clinical interest for CSDH. We performed a meta-analysis of published randomized controlled trials (RCTs) and used objective data as the primary outcomes to provide an evidence-based analysis of the efficacy of atorvastatin for CSDH treatment. Databases of MEDLINE (via PubMed), EMBASE, the Cochrane Library, Scopus, Web of Science, ScienceDirect, Chinese National Knowledge Infrastructure (CNKI), Cqvip database (CQVIP), and Wanfang database were systematically searched for RCTs reporting the use of atorvastatin for CSDH treatment. Odds ratio (OR), standard mean difference (SMD), and 95% confidence intervals (CIs) were used as summary statistics. I-square (I2) test was performed to assess the impact of study heterogeneity on the results of the meta-analysis. Nine relevant RCTs with 611 patients were identified for inclusion in this meta-analysis. Compared to controls, atorvastatin treatment had a significantly higher effectiveness (OR: 7.41, 95% CI: 3.32-16.52, P < 0.00001, I2 = 0%), lower hematoma volume (SMD: -0.46. 95% CI: -0.71 to -0.20, P = 0.0005, I2 = 0%), higher activities of daily living-Barthel Index (ADL-BI) (SMD: 2.07, 95% CI: 1.06-3.09, P < 0.0001, I2 = 92%), and smaller Chinese stroke scale (CSS) (SMD: -1.10, 95% CI: -1.72 to -0.48, P = 0.0005, I2 = 57%). In view of these findings, we conclude that the outcomes of experimental group are superior to the control group with respect to effectiveness, hematoma volume, ADL-BI, and CSS based on nine RCTs with 611 patients. Atorvastatin is beneficial to CSDH patients without surgery.
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Affiliation(s)
- Bo Wang
- Qingdao University Medical College Affiliated Yantai Yuhuangding Hospital, Yantai, Shandong, China
| | - Kangqi Li
- Qingdao University Medical College Affiliated Yantai Yuhuangding Hospital, Yantai, Shandong, China
| | - Chenyu Guo
- Qingdao University Medical College Affiliated Yantai Yuhuangding Hospital, Yantai, Shandong, China
| | - Zhe Wang
- Qingdao University Medical College Affiliated Yantai Yuhuangding Hospital, Yantai, Shandong, China
| | - Weiwei Zhu
- Qingdao University Medical College Affiliated Yantai Yuhuangding Hospital, Yantai, Shandong, China
| | - Congxiao Lu
- Qingdao University Medical College Affiliated Yantai Yuhuangding Hospital, Yantai, Shandong, China
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12
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Sato K, Horiguchi G, Teramukai S, Yoshida T, Shimizu F, Hashimoto N. Time-of-flight magnetic resonance angiography for detection of postoperative recurrence in patients with chronic subdural hematoma. Acta Neurol Belg 2023; 123:2167-2175. [PMID: 36478545 DOI: 10.1007/s13760-022-02154-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE Chronic subdural hematoma (CSDH) is associated with postoperative recurrence. Although various factors are involved in postoperative recurrence of CSDH, blood flow, especially in the middle meningeal artery (MMA), is considered to play an important role. We investigated whether the degree of signal intensity (SI) of the MMA on time-of-flight magnetic resonance angiography (TOF MRA) and various clinical factors are involved in recurrence of CSDH. METHODS The maximum SI of both MMAs was measured on TOF MRA images within 1 month before or after the initial surgery. RESULTS In total, 185 patients (20 with and 165 without recurrence of CSDH) were included in the analysis. The SI ratio and dementia were significant predictors of recurrence of CSDH (SI ratio: odds ratio [95% confidence interval (CI)] = 1.71 [1.32, 2.22], p < 0.0001; dementia: odds ratio [95% CI] = 7.41 [1.83, 30.1], p = 0.005). The estimated regression coefficients in the final model were 6.14 for the SI ratio and 1.28 for dementia. The risk score was derived according to these regression coefficients as follows: score = 5 × SI ratio + 1 (dementia: yes). With a score of 5, the predicted probability of recurrence was 2% [95% CI 0.7, 5.7], whereas with scores of 8 and 10, the probability was 43.3% [27.0, 61.1] and 89.5% [65.7, 97.5], respectively, which increased the risk of recurrence. CONCLUSION Patients with an increased SI ratio of the affected MMA on TOF MRA who underwent surgery for CSDH were significantly more likely to experience recurrence.
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Affiliation(s)
- Kimitoshi Sato
- Department of Neurosurgery, Seijinkai Shimizu Hospital, 12-2 Nakayoshimi-Cho, Nishikyo-Ku, Kyoto, 615-8237, Japan.
| | - Go Horiguchi
- Department of Biostatistics, Kyoto Prefectural University of Medicine Graduate School of Medical Science, Kyoto, Japan
| | - Satoshi Teramukai
- Department of Biostatistics, Kyoto Prefectural University of Medicine Graduate School of Medical Science, Kyoto, Japan
| | - Takashi Yoshida
- Department of Neurosurgery, Seijinkai Shimizu Hospital, 12-2 Nakayoshimi-Cho, Nishikyo-Ku, Kyoto, 615-8237, Japan
| | - Fuminori Shimizu
- Department of Neurosurgery, Seijinkai Shimizu Hospital, 12-2 Nakayoshimi-Cho, Nishikyo-Ku, Kyoto, 615-8237, Japan
| | - Naoya Hashimoto
- Department of Neurosurgery, Kyoto Prefectural University of Medicine Graduate School of Medical Science, Kyoto, Japan
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13
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Arturo Larco JL, Madhani SI, Liu Y, Abbasi M, Lylyk PN, Benike A, Shahid A, Tekin B, Quinton R, Savastano LE. Evaluation of an in vivo preclinical model for human middle meningeal artery embolization using the posterior intercostal artery of the swine. J Neurointerv Surg 2023; 15:924-930. [PMID: 35999050 DOI: 10.1136/jnis-2022-019105] [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: 05/02/2022] [Accepted: 07/23/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Embolization of the middle meningeal artery (MMA) is a promising minimally invasive technique that is gaining traction in the treatment of chronic subdural hematoma. Unfortunately, the human meninges and associated arteries are significantly larger than those of conventional laboratory animals, making the development of a clinically relevant animal model for testing of embolization agents elusive. OBJECTIVE To introduce the posterior intercostal artery (PIA) model in swine and provide anatomical, angiographic, histological, and procedural data to validate its relevance in modeling the human MMA. METHODS In human cadaveric specimens, 3D angiograms of the internal maxillary arteries (n=6) were obtained and the dura with MMA were harvested and histologically processed. Angiographic and histologic data of the human MMA were compared with the swine PIA (three animals). Then, embolization of the PIA (n=48 arteries) was conducted with liquid embolization agent (Onyx, Medtronic), and angiographic and histological results were assessed acutely (four animals) and after 30 days (two animals). RESULTS The human MMA has equivalent diameter, length, branching pattern, 3D trajectory, and wall structure to those of swine PIAs. Each swine has 12 to 14 PIAs (6-7 per side) suitable for acute or chronic embolization, which can be performed with high fidelity using the same devices, agents, and techniques currently used to embolize the MMA. The arterial wall structure and the acute and chronic histological findings in PIAs after embolization are comparable to those of humans. CONCLUSIONS This PIA model in swine could be used for research and development; objective benchmarking of agents, devices, and techniques; and in the training of neurointerventionalists.
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Affiliation(s)
| | | | - Yang Liu
- Global Institute of Future Technology, Shanghai Jiao Tong University, Shanghai, China
| | - Mehdi Abbasi
- Department of Radiology, Mayo Clinic Minnesota, Rochester, Minnesota, USA
| | - Pedro N Lylyk
- Department of Interventional Neuroradiology, Clinica Sagrada Familia, Buenos Aires, CABA, Argentina
| | - Amy Benike
- Department of Radiology, Mayo Clinic Minnesota, Rochester, Minnesota, USA
| | - Adnan Shahid
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Burak Tekin
- Department of Pathology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Reade Quinton
- Department of Pathology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Luis E Savastano
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurosurgery, UCSF, San Francisco, California, USA
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14
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Matsubara M, Yagi K, Minami Y, Kanda E, Sunada Y, Tao Y, Takai H, Shikata E, Hirai S, Matsubara S, Uno M. Preoperative elevated eosinophils in peripheral blood for prediction of postoperative recurrence of chronic subdural hematoma. J Neurosurg 2023; 139:708-713. [PMID: 36640094 DOI: 10.3171/2022.12.jns222432] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 12/07/2022] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Chronic subdural hematoma (CSDH) is a common neurological disease with a significant postoperative recurrence rate. There are numerous reported studies of the development of CSDH. In recent years, fibrinolysis, angiogenesis, and inflammation have all been identified as relevant factors in the development of CSDH. While several authors have reported risk factors associated with CSDH recurrence, differential blood count of leukocytes has not yet been discussed. Therefore, in this study the authors aimed to retrospectively investigate the association between differential blood leukocyte count and the rate of CSDH recurrence. METHODS The authors retrospectively reviewed 476 patients with 529 CSDHs who underwent surgery at a single institution between January 2011 and December 2021. After exclusion of patients who had not undergone a differential blood test of leukocytes preoperatively, CSDHs in 517 cerebral hemispheres of 466 patients were included in the study. Peripheral blood eosinophil counts ≥ 100/µL were considered eosinophil rich. RESULTS CSDHs in 494 cerebral hemispheres of 445 patients were followed up postoperatively for at least 3 months or until resolution indicated by CSDH disappearance. Postoperative recurrence of CSDH was observed in 46 cerebral hemispheres (9.3%). Among the preoperative differential blood counts of all leukocytes, eosinophils alone were significantly associated with CSDH recurrence (median [IQR] 76/µL [30-155/µL] vs 119/µL [39-217/µL]; p = 0.03). Multivariable regression analysis showed thrombocytopenia (adjusted OR [aOR] 5.23, 95% CI 1.85-14.79; p = 0.002), use of anticoagulant drugs (aOR 2.51, 95% CI 1.17-5.38; p = 0.02), hematoma volume (10 mL per increase) (aOR 1.08, 95% CI 1.00-1.16; p = 0.04), and eosinophil-rich peripheral blood (aOR 2.22, 95% CI 1.17-4.23; p = 0.02) were all independent predictors for CSDH recurrence. CONCLUSIONS This study showed that preoperative peripheral blood eosinophil count was an independent risk factor for CSDH recurrence. Therefore, patients with CSDH who have elevated eosinophils preoperatively in peripheral blood require careful follow-up.
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Affiliation(s)
| | | | | | - Eiichiro Kanda
- 2Medical Science, Kawasaki Medical School, Kurashiki, Okayama, Japan
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15
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Bumpetch D, Sitthinamsuwan B, Nunta-aree S. A Prospective Study of the Effect and Safety of Atorvastatin on the Recurrence of Chronic Subdural Hematoma after Burr Hole Surgery. Asian J Neurosurg 2023; 18:567-572. [PMID: 38152511 PMCID: PMC10749861 DOI: 10.1055/s-0043-1771372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023] Open
Abstract
Introduction Chronic subdural hematoma (CSDH) is a common neurosurgical condition. Recent studies showed efficacy of atorvastatin in reducing the requirement of surgical treatment. This study aimed to evaluate the efficacy and safety of atorvastatin in reducing the recurrence of CSDH after burr hole surgery. Methods This prospective study included patients with CSDH who underwent burr hole surgery. Atorvastatin at 20 mg per day was administered to all patients for 4 weeks postoperatively. The major outcome was the recurrence rate of CSDH at 8 weeks following the operation. Results Seventy-three patients who completed the 4-week course of atorvastatin were included. The mean age was 73.9 years. The most common cause of CSDH was falling. The mean hematoma volume was 106.3 mL. There was no adverse effect of atorvastatin in all of 73 patients. During the 8-week postoperative period, recurrent CSDH was found in 2 of 73 (2.7%) patients. In a comparison of the recurrence rate of CSDH between patients with use of atorvastatin from the present and previous studies (2.6-4.8%), and patients without use of atorvastatin from previous studies (9.8-19%), a marked reduction in recurrent CSDH after burr hole surgery was found in patients with use of atorvastatin. Conclusion An administration of atorvastatin of 20 mg daily for 4 weeks following burr hole surgery is safe and may be helpful in reducing the recurrence rate of CSDH after burr hole surgery.
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Affiliation(s)
- Duangkamol Bumpetch
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Department of Surgery, Nan Hospital, Nan, Thailand
| | - Bunpot Sitthinamsuwan
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sarun Nunta-aree
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Chen C, Xiong Y, Huang X, Guo X, Kang X, Zhou J, Pan Z, Zheng H, Zheng S, Wang L, Hu W, Zhuang L, Zheng F. Subperiosteal/subgaleal drainage vs. subdural drainage for chronic subdural hematoma: A meta-analysis of postoperative outcomes. PLoS One 2023; 18:e0288872. [PMID: 37527264 PMCID: PMC10393133 DOI: 10.1371/journal.pone.0288872] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 07/05/2023] [Indexed: 08/03/2023] Open
Abstract
BACKGROUND Chronic subdural hematoma (CSDH) is commonly treated via surgical removal of the hematoma, placement of a routine indwelling drainage tube, and continuous drainage to ensure that the blood does not re-aggregate following removal. However, the optimal location for placement of the drainage tube remains to be determined. OBJECTIVES To aid in establishing a reference for selecting the optimal method, we compared the effects of different drainage tube placements on CSDH prognosis via a systematic review and meta-analysis of previous clinical studies. DATA SOURCES PubMed, Embase, and Cochrane databases. STUDY ELIGIBILITY CRITERIA We searched for clinical studies comparing the outcomes of subperiosteal/subgaleal drainage (SPGD) and subdural drainage (SDD) for CSDH published in English prior to April 1, 2022. PARTICIPANTS The final analysis included 15 studies involving 4,318 patients. RESULTS Our analysis of the pooled results revealed no significant differences in recurrence rate between the SDD and SPGD groups. We also observed no significant differences in mortality or rates of postoperative complications (infection, pneumocephalus, or epilepsy) between the SDD and SPGD groups. CONCLUSIONS These results suggest that the choice of SDD vs. SPGD has no significant effect on CSDH prognosis, highlighting SPGD as an alternative treatment option for CSDH.
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Affiliation(s)
- Chunhui Chen
- Department of Neurosurgery, the Second Affiliated Hospital, Fujian Medical University, Quanzhou, Fujian Province, China
| | - Yu Xiong
- Department of Neurosurgery, the Second Affiliated Hospital, Fujian Medical University, Quanzhou, Fujian Province, China
| | - Xinyue Huang
- Department of Neurosurgery, the Second Affiliated Hospital, Fujian Medical University, Quanzhou, Fujian Province, China
| | - Xiumei Guo
- Department of Neurosurgery, the Second Affiliated Hospital, Fujian Medical University, Quanzhou, Fujian Province, China
- Department of Neurology, the Second Affiliated Hospital, Fujian Medical University, Quanzhou, Fujian Province, China
| | - Xiaodong Kang
- Department of Neurosurgery, the Second Affiliated Hospital, Fujian Medical University, Quanzhou, Fujian Province, China
| | - Jianfeng Zhou
- Department of Neurosurgery, the Second Affiliated Hospital, Fujian Medical University, Quanzhou, Fujian Province, China
| | - Zhigang Pan
- Department of Neurosurgery, the Second Affiliated Hospital, Fujian Medical University, Quanzhou, Fujian Province, China
| | - Hanlin Zheng
- Department of Neurosurgery, the Second Affiliated Hospital, Fujian Medical University, Quanzhou, Fujian Province, China
| | - Shuni Zheng
- Division of Public Management, the Second Affiliated Hospital, Fujian Medical University, Quanzhou, Fujian Province, China
| | - Linxing Wang
- Department of Neurology, the Second Affiliated Hospital, Fujian Medical University, Quanzhou, Fujian Province, China
| | - Weipeng Hu
- Department of Neurosurgery, the Second Affiliated Hospital, Fujian Medical University, Quanzhou, Fujian Province, China
| | - Liming Zhuang
- Department of Pharmacy, the Second Affiliated Hospital, Fujian Medical University, Quanzhou, Fujian Province, China
| | - Feng Zheng
- Department of Neurosurgery, the Second Affiliated Hospital, Fujian Medical University, Quanzhou, Fujian Province, China
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Melander N, Sönnerqvist C, Olivecrona M. Non-surgical patient characteristics best predict outcome after 6 months in patients surgically treated for chronic subdural haematoma. J Clin Neurosci 2023; 114:151-157. [PMID: 37429160 DOI: 10.1016/j.jocn.2023.07.001] [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: 04/19/2023] [Revised: 06/18/2023] [Accepted: 07/01/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND Chronic subdural haematoma (CSDH) is one of the most common conditions encountered in neurosurgical practice. After surgery, the patients often improve dramatically; but their long-term outcome is more uncertain. The purpose of this study was to investigate predictors of outcome 6 months after surgery. METHODS Retrospective data were collected on patients in Orebro County, Sweden, who had undergone surgery for CSDH at the Orebro University Hospital between 2013 and 2019. The outcomes were defined as favourable or unfavourable in terms of the modified Rankin Scale (mRS). A favourable outcome was defined as either mRS 0-2 or an unchanged mRS score in patients scoring 3-5 before surgery. From the variables in the data collected, a multiple logistic regression model was constructed. RESULTS The study comprised 180 patients, of whom 134 (74.4%) were male. Median age was 79.2 years (IQR 71.7-85.5), and 129 (71.7%) patients had a favourable outcome at 6 months. In the group with an unfavourable outcome, 18 (10%) had died and 33 (18.3%) had either lost their independence in daily living or become somewhat less independent. The final multiple logistic regression model consisted of pre-surgery variables only: age (OR 0.92, 95% CI 0.87-0.97), CRP (OR 0.96, 95% CI 0.94-0.99), GCS > 13 (OR 3.66, 95% CI 1.09-12.3), Hb (OR 1.03, 95% CI 1.00-1.05), and ASA score < 3 (OR 2.58, 95% CI 0.98-6.79). The whole model had an AUC of 0.88. CONCLUSION CSDH requiring surgery is associated with high morbidity and mortality at 6 months after surgery. Age, CRP, GCS, Hb and ASA score on admission for surgery are the variables that best predicts outcome. This knowledge can help to identify the patients at greatest risk for an unfavourable outcome, who may need additional support from the health care system. UNSTRUCTURED ABSTRACT Chronic subdural haematoma (CSDH) is one of the most common conditions encountered in neurosurgical practice. After surgery, the patients often improve dramatically; but their long-term outcome is more uncertain. The purpose of this study was to investigate predictors of outcome, in terms of the modified Rankin Scale (mRS), 6 months after surgery. The study comprised 180 patients, of whom 134 (74.4%) were male. Median age was 79.2 years (IQR 71.7-85.5), and 129 (71.7%) patients had a favourable outcome at 6 months. In the group with an unfavourable outcome, 18 (10%) had died and 33 (18.3%) had either lost their independence in daily living or become somewhat less independent. The final multiple logistic regression model consisted of pre-surgery variables only: age (OR 0.92, 95% CI 0.87-0.97), CRP (OR 0.96, 95% CI 0.94-0.99), GCS > 13 (OR 3.66, 95% CI 1.09-12.3), Hb (OR 1.03, 95% CI 1.00-1.05), and ASA score < 3 (OR 2.58, 95% CI 0.98-6.79). The whole model had an AUC of 0.88. In conclusion, CSDH requiring surgery is associated with high morbidity and mortality at 6 months after surgery. Age, CRP, GCS, Hb and ASA score on admission for surgery are the variables that best predicts outcome. This knowledge can help to identify the patients at greatest risk for an unfavourable outcome, who may need additional support from the health care system.
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Affiliation(s)
- Nils Melander
- Department of Neurology, Faculty of Medicine and Health, Örebro University, SE-701 82 Örebro, Sweden.
| | - Caroline Sönnerqvist
- Department of Paediatrics, Faculty of Medicine and Health, Örebro University, SE-701 82 Örebro, Sweden
| | - Magnus Olivecrona
- Department of Neurosurgery, Faculty of Medicine and Health, Örebro University, SE-701 82 Örebro, Sweden
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Huang YW, Li ZP, Yin XS. Intraoperative irrigation of artificial cerebrospinal fluid and temperature of irrigation fluid for chronic subdural hematoma: a systematic review and meta-analysis. Front Neurol 2023; 14:1218334. [PMID: 37483449 PMCID: PMC10359978 DOI: 10.3389/fneur.2023.1218334] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 06/16/2023] [Indexed: 07/25/2023] Open
Abstract
Purpose To systematically review the different types of irrigation fluid and the different temperatures of irrigation fluid on postoperative recurrence rates in the evacuation of chronic subdural hematoma (CSDH). Methods We conducted a comprehensive search of electronic databases, including PubMed, Embase, the Cochrane Library, the China National Knowledge Infrastructure (CNKI), WanFang, the Chinese VIP Information (VIP), and China Biology Medicine (CBM), and reference lists of relevant studies to identify all eligible studies. Two reviewers independently screened the titles and abstracts for inclusion, and the full-text articles were assessed for eligibility based on predetermined inclusion and exclusion criteria. Data were extracted using a standardized form, and the quality of the studies was assessed using a risk of bias tool. Meta-analyses were performed using a fixed-or random-effects model, and heterogeneity was assessed using the I2 statistic. The primary endpoint was the postoperative recurrence rate. Results After stringent screening, a total of 11 studies were identified, including six English publications, four Chinese publications, and one Japanese publication, involving a population of 29,846 patients. Our meta-analysis provides evidence that artificial cerebrospinal fluid (ACF) could decrease the post-operative recurrence rate by 47% after the evacuation of CSDH when compared to normal saline (NS) [(odds ratio) OR 0.53, 95% confidence intervals (CI): 0.31-0.90, p = 0.02, I2 = 67%]. Besides, the irrigation fluid at body temperature could decrease the postoperative recurrence rate of CSDH by 64% when compared to room temperature (OR = 0.36, 95% CI = 0.22-0.59, p < 0.0001, I2 = 0%). Conclusion Our analysis revealed significant difference in the choice of irrigation fluid for CSDH surgery. Notably, we found that irrigation with fluid at body temperature demonstrated superiority over irrigation with fluid at room temperature, resulting in fewer instances of recurrence. This straightforward technique is both safe and widely available, providing an opportunity to optimize outcomes for patients with CSDH. Our findings suggest that the use of body-temperature NS or ACF of room temperature during operation should be considered a standard of procedure in CSDH surgery. Nevertheless, whether the different temperature of ACF could be considered a standard of procedure in CSDH surgery still need high-quality RCTs to further identify. Systematic review registration https://www.crd.york.ac.uk/prospero/; Identifier CRD42023424344.
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Affiliation(s)
- Yong-Wei Huang
- Department of Neurosurgery, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan, China
| | - Zong-Ping Li
- Department of Neurosurgery, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan, China
| | - Xiao-Shuang Yin
- Department of Immunology, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, Sichuan, China
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Mirkarimi T, Salek M. An 85-Year-Old Man with Gradual Decrease in the Level of Consciousness and Vomiting; a Photo Quiz. ARCHIVES OF ACADEMIC EMERGENCY MEDICINE 2023; 11:e37. [PMID: 37215233 PMCID: PMC10197904 DOI: 10.22037/aaem.v11i1.2030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Affiliation(s)
- Talayeh Mirkarimi
- Emergency Department, Alborz University of Medical Science, Karaj, Iran
| | - Mohammad Salek
- Haematology, Oncology and Stem cell Transplantation research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Karibe H, Narisawa A, Nagai A, Yamanouchi S, Kameyama M, Nakagawa A, Tominaga T. Incidence of Chronic Subdural Hematoma after Mild Head Trauma in Elderly Patients with or without Pre-traumatic Conditioning of Anti-thrombotic Drugs. Neurol Med Chir (Tokyo) 2023; 63:91-96. [PMID: 36682795 PMCID: PMC10072887 DOI: 10.2176/jns-nmc.2022-0327] [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] [Indexed: 01/20/2023] Open
Abstract
Anti-thrombotic drugs may increase the risk for chronic subdural hematoma (CSDH). However, whether to continue or discontinue/counteract these drugs has not been investigated in patients with mild head trauma. CSDH incidence after mild head trauma, as well as the risk for CSDH in patients with anti-thrombotic drugs, were investigated in this study. The study included 765 consecutive elderly (>65 y.o.) patients with mild head trauma and an initial Glasgow Coma Scale (GCS) score of 14 or 15. All patients received initial CT within 24 hours after trauma and were re-examined 30 days after trauma to detect CSDH formation, repeating for every 30 days to examine symptomatic CSDH progression. Patients were divided into two groups, with anti-thrombotic drugs (n = 195) or without them (n = 263), to investigate the influence of pre-traumatic conditioning with anti-thrombotic drugs on CSDH. The whole sample was 458 out of 765 cases. The incidence of CSDH formation was 91 out of 458 cases (19.9%) after mild head trauma, with no significant difference between with and without anti-thrombotic drugs. CSDH progressed as symptomatic in 21 out of 458 cases (4.6%), with no significant difference between with and without anti-thrombotic drugs. Pre-traumatic conditioning with anti-thrombotic drugs and its continuation after trauma did not affect the incidence of formation or symptomatic progression of CSDH. This finding suggests that discontinuing and/or counteracting anti-thrombotic drugs may be unnecessary in patients with mild head trauma.
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Affiliation(s)
| | | | - Arata Nagai
- Department of Neurosurgery, Sendai City Hospital
- Department of Neurosurgery, Tohoku University Graduate School of Medicine
| | | | | | - Atsuhiro Nakagawa
- Department of Neurosurgery, Tohoku University Graduate School of Medicine
| | - Teiji Tominaga
- Department of Neurosurgery, Tohoku University Graduate School of Medicine
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Butterfly needle tap and suction (BTS) technique: a treatment for recurrent chronic subdural hematoma after burr hole craniostomy. Acta Neurochir (Wien) 2023; 165:841-848. [PMID: 36918432 DOI: 10.1007/s00701-023-05543-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 03/01/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND In this study, we propose a butterfly needle tap and suction (BTS) technique for recurrent chronic subdural hematoma (CSDH) as an alternative to reoperation with burr hole craniostomy (BHC) and investigate its efficacy and safety. The procedure involves percutaneous puncture through the burr hole created during the previous surgery and subsequent hematoma evacuation using a butterfly needle. METHODS This retrospective study included patients who underwent BTS for CSDH at Ogaki Municipal Hospital between January 2017 and December 2020. The follow-up CT scans were reviewed after several weeks. We evaluated the number of percutaneous punctures required to resolve CSDH during the BTS technique, the volume of the evacuated hematoma, and procedure-related complications. RESULTS Twenty-six patients were enrolled in the study, 21 of whom achieved resolution of the hematoma using punctures with the BTS technique alone (mean, 2.2 ± 1.5). Five patients had a recurrence of hematoma after one or more punctures during the BTS technique, and they underwent reoperation with BHC according to the surgeon's decision or patient requests. Among the 55 punctures, 43.0 ± 16.0 ml of hematoma was evacuated per puncture. The evacuated hematoma volume was 41.9 ± 16.4 ml in the BTS-alone group and 49.4 ± 12.9 ml in the reoperation group, with no significant difference (p = 0.25). Three patients complained of a headache during the puncture procedure, and no other complications, including intracranial hemorrhage or infection, were reported therein. CONCLUSIONS The BTS technique is an effective alternative to reoperation with BHC.
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Takroni R, Zagzoog N, Patel N, Martyniuk A, Singh S, Farrokhyar F, Trivedi A, Alotaibi M, Algird A. Comparison of Two Drainage Systems on Chronic Subdural Hematoma Recurrence. J Neurol Surg A Cent Eur Neurosurg 2023; 84:157-166. [PMID: 34784622 DOI: 10.1055/a-1698-6212] [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: 10/19/2022]
Abstract
BACKGROUND Chronic subdural hematoma (CSDH) is a common type of intracranial hemorrhage, especially among the elderly, with a recurrence rate as high as 33%. Little is known about the best type of drainage system and its relationship with recurrence. In this study, we compare the use of two drainage systems on the recurrence rate of CSDH. METHODS We retrospectively analyzed the charts of 172 CSDH patients treated with bedside twist drill craniostomy (TDC) and subdural drain insertion. Patients were divided into two groups: group A (n = 123) received a pediatric size nasogastric tube [NGT]), whereas group B (n = 49) had a drain commonly used for external ventricular drainage (EVD). Various demographic and radiologic data were collected. Our main outcome was recurrence, defined as symptomatic re-accumulation of hematoma on the previously operated side within 3 months. RESULTS In all, 212 cases of CSDH were treated in 172 patients. The majority of patients were male (78%) and had a history of previous head trauma (73%). Seventeen cases had recurrence, 11 in group A and 6 in group B. The use of antiplatelet and anticoagulation agents was associated with recurrence (p = 0.038 and 0.05, respectively). There was no difference between both groups in terms of recurrence (odds ratio [OR] = 1.42; 95% confidence interval [CI]: 0.49-4.08; p = 0.573). CONCLUSION CSDH is a common disease with a high rate of recurrence. Although using a drain postoperatively has shown to reduce the incidence of recurrence, little is known about the best type of drain to use. Our analysis showed no difference in the recurrence rate between using the pediatric size NGT and the EVD catheter post-TDC.
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Affiliation(s)
- Radwan Takroni
- Division of Neurosurgery, Department of Surgery, Hamilton General Hospital, Hamilton, Ontario, Canada
- King Faisal Medical City for Southern Regions, Abha, Saudi Arabia
| | - Nirmeen Zagzoog
- Division of Neurosurgery, Department of Surgery, Hamilton General Hospital, Hamilton, Ontario, Canada
| | - Nimita Patel
- Department of Health, Evidence and Impact, McMaster University, Ontario, Canada
| | - Amanda Martyniuk
- Division of Neurosurgery, Department of Surgery, Hamilton General Hospital, Hamilton, Ontario, Canada
| | - Sheila Singh
- Division of Neurosurgery, Department of Surgery, Hamilton General Hospital, Hamilton, Ontario, Canada
| | - Forough Farrokhyar
- Department of Health, Evidence and Impact, McMaster University, Ontario, Canada
| | - Arunachala Trivedi
- Michael G. DeGroote School of Medicine, McMaster University, Ontario, Canada
| | - Mazen Alotaibi
- Division of Neurosurgery, Department of Surgery, Hamilton General Hospital, Hamilton, Ontario, Canada
| | - Almunder Algird
- Division of Neurosurgery, Department of Surgery, Hamilton General Hospital, Hamilton, Ontario, Canada
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Shibahashi K, Ohbe H, Yasunaga H. Adjuvant oral tranexamic acid and reoperation after burr hole surgery in patients with chronic subdural hematoma: propensity score-matched analysis using a nationwide inpatient database. J Neurosurg 2023; 138:430-436. [PMID: 35901677 DOI: 10.3171/2022.5.jns22664] [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: 03/19/2022] [Accepted: 05/25/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Adjuvant medical treatment to reduce the recurrence rate after burr hole surgery for chronic subdural hematoma (CSDH) has not yet been established. This study aimed to investigate the association between tranexamic acid (TXA) use after burr hole surgery and the reoperation rate in patients with CSDH. METHODS This observational study used the Japanese Diagnostic Procedure Combination inpatient database, a nationwide inpatient database in Japan, from July 1, 2010, to March 31, 2019. The authors identified patients who were hospitalized for CSDH and underwent burr hole surgery within 2 days of admission. The primary outcome measure was reoperation within 1 year after surgery. One-to-one propensity score-matched analysis was performed to compare the outcomes between patients who started oral TXA within 2 days after surgery (TXA users) and those who did not (TXA nonusers). Robustness of the analyses was assessed using the instrumental variable analysis. RESULTS Of the 149,543 patients with CSDH treated at 1100 hospitals, 7366 (4.9%) were TXA users. Propensity score matching created 6564 matched pairs with highly balanced baseline characteristics. The reoperation rate was significantly lower in TXA users than in nonusers (1.9% vs 6.1%, p < 0.001) with a risk difference of -4.1% (95% CI -4.8% to -3.4%). There was no significant difference in composite adverse events (0.6% vs 0.5%, p = 0.817). Total hospitalization costs were also significantly lower in TXA users than in nonusers ($5229 vs $5344 [USD], p < 0.001). The results of the instrumental variable analysis were consistent with those of the propensity score-matched analysis. CONCLUSIONS Findings of this study, using a nationwide inpatient database, suggest that adjuvant TXA use after burr hole surgery was associated with a reduced reoperation rate in patients with CSDH.
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Affiliation(s)
- Keita Shibahashi
- 1Department of Clinical Epidemiology and Health Economics, School of Public Health, University of Tokyo; and.,2Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Hiroyuki Ohbe
- 1Department of Clinical Epidemiology and Health Economics, School of Public Health, University of Tokyo; and
| | - Hideo Yasunaga
- 1Department of Clinical Epidemiology and Health Economics, School of Public Health, University of Tokyo; and
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Biswas S, MacArthur J, Sarkar V, Thompson H, Saleemi M, George KJ. Development and Validation of the Chronic Subdural HematOma Referral oUtcome Prediction Using Statistics (CHORUS) Score: A Retrospective Study at a National Tertiary Center. World Neurosurg 2023; 170:e724-e736. [PMID: 36442777 DOI: 10.1016/j.wneu.2022.11.097] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 11/21/2022] [Accepted: 11/22/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Chronic subdural hematoma (CSDH) is a common neurosurgical condition with an increasing rate of patient referrals. CSDH referral decision-making is a subjective clinical process, and our aim was to develop a simple scoring system capable of acting as a decision support tool aiding referral triage. METHODS A single tertiary center retrospective case series analysis of all CSDH patient referrals from 2015 to 2020 was conducted. Ten independent variables used in the referral process were analyzed to predict the binary outcome of either accepting or rejecting the CSDH referral. Following feature selection analysis, a multivariable scoring system was developed and evaluated. RESULTS 1500 patient referrals were included. Stepwise multivariable logistic and least absolute shrinkage and selection operator regression identified age <85 years, the presence of headaches, dementia, motor weakness, radiological midline shift, a reasonable premorbid quality of life, and a large sized hematoma to be statistically significant predictors of CSDH referral acceptance (P <0.04). These variables derived a scoring system ranging from -9 to 6 with an optimal cut-off for referral acceptance at any score >1 (P <0.0001). This scoring system demonstrated optimal calibration (brier score loss = 0.0552), with a score >1 predicting referral acceptance with an area under the curve of 0.899 (0.876-0.922), a sensitivity of 83.838% (76.587-91.089), and a specificity of 96.000% (94.080-97.920). CONCLUSIONS Certain patient specific clinical and radiological characteristics can predict the acceptance or rejection of a CSDH referral. Considering the precision of this scoring system, it has the potential for effectively triaging CSDH referrals.
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Affiliation(s)
- Sayan Biswas
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Joshua MacArthur
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Ved Sarkar
- Division of Computer Information Systems, De Anza College, Cupertino, California, USA
| | - Helena Thompson
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Mohammad Saleemi
- Department of Neurosurgery, Salford Royal Hospital, Manchester, UK
| | - K Joshi George
- Department of Neurosurgery, Salford Royal Hospital, Manchester, UK.
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25
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Biswas S, MacArthur JI, Pandit A, McMenemy L, Sarkar V, Thompson H, Saleemi MS, Chintzewen J, Almansoor ZR, Chai XT, Hardman E, Torrie C, Holt M, Hanna T, Sobieraj A, Toma A, George KJ. Predicting neurosurgical referral outcomes in patients with chronic subdural hematomas using machine learning algorithms - A multi-center feasibility study. Surg Neurol Int 2023; 14:22. [PMID: 36751456 PMCID: PMC9899452 DOI: 10.25259/sni_1086_2022] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 12/24/2022] [Indexed: 01/22/2023] Open
Abstract
Background Chronic subdural hematoma (CSDH) incidence and referral rates to neurosurgery are increasing. Accurate and automated evidence-based referral decision-support tools that can triage referrals are required. Our objective was to explore the feasibility of machine learning (ML) algorithms in predicting the outcome of a CSDH referral made to neurosurgery and to examine their reliability on external validation. Methods Multicenter retrospective case series conducted from 2015 to 2020, analyzing all CSDH patient referrals at two neurosurgical centers in the United Kingdom. 10 independent predictor variables were analyzed to predict the binary outcome of either accepting (for surgical treatment) or rejecting the CSDH referral with the aim of conservative management. 5 ML algorithms were developed and externally tested to determine the most reliable model for deployment. Results 1500 referrals in the internal cohort were analyzed, with 70% being rejected referrals. On a holdout set of 450 patients, the artificial neural network demonstrated an accuracy of 96.222% (94.444-97.778), an area under the receiver operating curve (AUC) of 0.951 (0.927-0.973) and a brier score loss of 0.037 (0.022-0.056). On a 1713 external validation patient cohort, the model demonstrated an AUC of 0.896 (0.878-0.912) and an accuracy of 92.294% (90.952-93.520). This model is publicly deployed: https://medmlanalytics.com/neural-analysis-model/. Conclusion ML models can accurately predict referral outcomes and can potentially be used in clinical practice as CSDH referral decision making support tools. The growing demand in healthcare, combined with increasing digitization of health records raises the opportunity for ML algorithms to be used for decision making in complex clinical scenarios.
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Affiliation(s)
- Sayan Biswas
- Department of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom,Corresponding author: Sayan Biswas, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom.
| | - Joshua Ian MacArthur
- Department of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Anand Pandit
- Department of High-Dimensional Neurology, University College London, London, United Kingdom
| | - Lareyna McMenemy
- Department of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Ved Sarkar
- Department of Computer Information Systems, De Anza College, Cupertino, United States
| | - Helena Thompson
- Department of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Mohammad Saleem Saleemi
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Manchester, United Kingdom
| | - Julian Chintzewen
- Department of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Zahra Rose Almansoor
- Department of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Xin Tian Chai
- Department of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Emily Hardman
- Department of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Christopher Torrie
- Department of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Maya Holt
- Department of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Thomas Hanna
- Department of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Aleksandra Sobieraj
- Department of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Ahmed Toma
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - K. Joshi George
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Manchester, United Kingdom
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Bartley A, Bartek J, Jakola AS, Sundblom J, Fält M, Förander P, Marklund N, Tisell M. Effect of Irrigation Fluid Temperature on Recurrence in the Evacuation of Chronic Subdural Hematoma: A Randomized Clinical Trial. JAMA Neurol 2023; 80:58-63. [PMID: 36409480 PMCID: PMC9679960 DOI: 10.1001/jamaneurol.2022.4133] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Importance The effect of a physical property of irrigation fluid (at body vs room temperature) on recurrence rate in the evacuation of chronic subdural hematoma (cSDH) needs further study. Objective To explore whether irrigation fluid temperature has an influence on cSDH recurrence. Design, Setting, and Participants This was a multicenter randomized clinical trial performed between March 16, 2016, and May 30, 2020. The follow-up period was 6 months. The study was conducted at 3 neurosurgical departments in Sweden. All patients older than 18 years undergoing cSDH evacuation during the study period were screened for eligibility in the study. Interventions The study participants were randomly assigned by 1:1 block randomization to the cSDH evacuation procedure with irrigation fluid at room temperature (RT group) or at body temperature (BT group). Main Outcomes and Measures The primary end point was recurrence requiring reoperation within 6 months. Secondary end points were mortality, health-related quality of life, and complication frequency. Results At 6 months after surgery, 541 patients (mean [SD] age, 75.8 [9.8] years; 395 men [73%]) had a complete follow-up according to protocol. There were 39 of 277 recurrences (14%) requiring reoperation in the RT group, compared with 16 of 264 recurrences (6%) in the BT group (odds ratio, 2.56; 95% CI, 1.38-4.66; P < .001). There were no significant differences in mortality, health-related quality of life, or complication frequency. Conclusions and Relevance In this study, irrigation at body temperature was superior to irrigation at room temperature in terms of fewer recurrences. This is a simple, safe, and readily available technique to optimize outcome in patients with cSDH. When irrigation is used in cSDH surgery, irrigation fluid at body temperature should be considered standard of care. Trial Registration ClincalTrials.gov Identifier: NCT02757235.
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Affiliation(s)
- Andreas Bartley
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, University of Gothenburg, Sahlgrenska Academy, Gothenburg, Sweden,Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jiri Bartek
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden,Department of Neurosurgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Asgeir S. Jakola
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, University of Gothenburg, Sahlgrenska Academy, Gothenburg, Sweden,Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jimmy Sundblom
- Department of Medical Sciences; Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Marie Fält
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Petter Förander
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Niklas Marklund
- Department of Clinical Sciences Lund, Neurosurgery, Lund University, Skåne University Hospital, Lund, Sweden
| | - Magnus Tisell
- Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, University of Gothenburg, Sahlgrenska Academy, Gothenburg, Sweden,Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden
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Chan DYC, Cheung EYH, Hui KH, Leung CMS, Ng SCP, Mak WK, Wong GKC, Chan TMD, Poon WS. ABC/2 formula for “bedside” postoperative pneumocephalus volume measurement. Chin Neurosurg J 2022; 8:18. [PMID: 35922864 PMCID: PMC9347102 DOI: 10.1186/s41016-022-00287-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 07/05/2022] [Indexed: 11/10/2022] Open
Abstract
Background Postoperative pneumocephalus is associated with a higher risk of recurrence of chronic subdural hematoma (cSDH). However, there is no verified simple way to measure the pneumocephalus volume at the bedside for daily clinical use. The ABC/2 method was shown to be a simple and reliable technique to estimate volumes of intracranial lesions, such as intracranial hematomas. This study aims to evaluate the accuracy of the ABC/2 formula in estimating volumes of pneumocephalus, as compared to the gold standard with computer-assisted volumetric analysis. Methods A total of 141 postoperative computed tomographic (CT) brain scans of cSDH patients with burr-hole drainage were analysed. Pneumocephalus volume was measured independently by both the ABC/2 formula and the computer-assisted volumetric measurement. For the computer-assisted measurement, the volume of the air was semiautomatically segmented and calculated by computer software. Linear regression was used to determine the correlation between the ABC/2 method and computer-assisted measurement. Results The postoperative pneumocephalus volume after bilateral burr-hole drainage was significantly larger than that of unilateral burr-hole drainage (29.34 ml versus 12.21 ml, p < 0.001). The estimated volumes by the formula ABC/2 significantly correlated to the volumes as measured by the computer-assisted volumetric technique, with r = 0.992 (p < 0.001). The Pearson correlation coefficient is very close to 1, which signifies a very strong positive correlation, and it is statistically significant. Conclusions An excellent correlation is observed between the ABC/2 method and the computer-assisted measurement. This study verified that the ABC/2 method is an accurate and simple “bedside” technique to estimate pneumocephalus volume. • The ABC/2 method is an accurate and simple “bedside” technique to estimate pneumocephalus volume. • The postoperative pneumocephalus volume after bilateral burr-hole drainage was significantly larger than that of unilateral burr-hole drainage (29.34 ml versus 12.21 ml, p < 0.001). • The estimated volumes of pneumocephalus by the formula ABC/2 were significantly correlated to the volumes as measured by the computer-assisted volumetric technique, with r = 0.992 (p < 0.001).
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Abstract
In this paper, I review the historical changes in the etiological concepts and surgical treatments for chronic subdural hematoma (CSDH) across the world and in Japan. I also examine future problems associated with its surgical procedures and medical costs. CSDH was first reported by Wepfer in 1657 as "delayed apoplexy." In 1857, Virchow described the famous concept of so-called "pachymeningitis hemorrhagica interna." He considered that the etiology of CSDH involved inflammation. In 1914, Trotter described the origin of CSDH as traumatic. Currently, CSDH is considered to arise with a first leak of blood from dural border cells after mild trauma. Inflammatory cells are then drawn to the border cell layer. At this point, new membranes form from activated inflammation; then, the hematoma enlarges, promoted by angiogenic factors and new capillaries. In 1883, Hulke reported successful trepanning of a patient with CSDH. Burr holes and craniotomy for removal of the hematoma were subsequently reported, and new methods were developed over the course of several decades around the world. In Japan, after the first report by Nakada in 1938, many Japanese pioneering figures of neurological surgery have studied CSDH. After Mandai reported the middle meningeal artery embolization in 2000, this method is now considered useful as an initial or second treatment for CSDH. However, the age of patients is increasing, so more minimally invasive surgeries and useful pharmacotherapies are needed. We must also consider the costs for treating CSDH, because of the increasing numbers of surgical cases.
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Affiliation(s)
- Masaaki UNO
- Department of Neurosurgery, Kawasaki Medical School, Kurashiki, Okayama, Japan
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Al-Taei O, Al-Mirza A, Ali M, Al-Kalbani H, Al-Saadi T. Prevalence and Outcomes of Geriatric Traumatic Brain Injury in Developing Countries: A Retrospective Study. INDIAN JOURNAL OF NEUROTRAUMA 2022. [DOI: 10.1055/s-0041-1740942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Abstract
Introduction The world populace is aging and it is anticipated that 2 billion people will be older than 60 years by 2050. Traumatic brain injury (TBI) is a major cause of death and disability worldwide. In the United States, 2.8 million people pursue medical attention yearly. TBI exemplifies a leading cause of mortality and morbidity among the geriatric age group worldwide.
Methods A retrospective study of geriatric cases who were admitted to the Neurosurgery Department in Khoula Hospital from January 1, 2016, to December 31, 2019, was conducted. Patients' demographics, risk factors, neuro-vital sign, diagnosis, Glasgow coma scale (GCS) on arrival, treatment types, and length of stay (LOS) were recorded.
Results Two hundred and thirty-four patients were admitted due to TBI in four years period. Seventy-five percent of the study cohort were more than 75 years old. Male to female ratio was 2.4:1. Subdural hematoma (SDH) was the most common TBI diagnosis based on computed tomography (77.4%). Most of the patients were having GCS scores of 14 to 15 (67.9%). Sixteen percent of the patients received antiepileptic medications. The majority of the patients underwent surgical intervention (70.5%). Eighty percent of the patients stayed in the hospital for less than 15 days. There was a significant difference between the LOS and type of surgery. Subarachnoid hemorrhage was found to have the highest mean age (79.7 years). Intracerebral hemorrhage patients had the longest LOS in the hospital with a mean of 44.2 days. There was no significant difference between the age of patients and type of surgery.
Conclusion The number of TBI in the elderly population is increasing annually. The most common type of TBI in our cohort was SDH and most of the patients were treated with burr hole surgery.
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Affiliation(s)
- Omar Al-Taei
- Sultan Qaboos University College of Medicine, Sultanate of Oman-Muscat, Al-Khoudh, Oman
| | - Abdulrahman Al-Mirza
- Sultan Qaboos University College of Medicine, Sultanate of Oman-Muscat, Al-Khoudh, Oman
| | - Mohammed Ali
- Neurosurgery Department, Khoula Hospital, Muscat, Oman
| | - Humaid Al-Kalbani
- Department of Ophthalmology, Al-Buraimi Hospital, Ministry of Health, Sultanate of Oman, Oman
| | - Tariq Al-Saadi
- Neurosurgery Department, Khoula Hospital, Muscat, Oman
- Department of Neurology and Neurosurgery, Montreal Neurological Institute, Faculty of Medicine, McGill University, Quebec, Canada
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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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Posti JP, Luoto TM, Sipilä JOT, Rautava P, Kytö V. Prognosis of patients with operated chronic subdural hematoma. Sci Rep 2022; 12:7020. [PMID: 35488040 PMCID: PMC9054845 DOI: 10.1038/s41598-022-10992-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 04/14/2022] [Indexed: 12/11/2022] Open
Abstract
Chronic subdural hematoma (cSDH), previously considered fairly benign and easy to treat, is now viewed a possible sign of incipient clinical decline. We investigated case-fatality, excess fatality and need for reoperations following operated cSDH in a nationwide setting focusing on patient-related characteristics. Finnish nationwide databases were searched for all admissions with operated cSDH as well as later deaths in adults (≥ 16 years) during 2004–2017. There were 8539 patients with an evacuated cSDH (68% men) with a mean age of 73.0 (± 12.8) years. During the follow-up, 3805 (45%) patients died. In-hospital case-fatality was 0.7% (n = 60) and 30-day case-fatality 4.2% (n = 358). The 1-year case-fatality was 14.3% (95% CI = 13.4–15.2%) among men and 15.3% (95% CI = 14.0–16.7%) among women. Comorbidity burden, older age, and alcoholism were significantly associated with fatality. One-year excess fatality rate compared to general Finnish population was 9.1% (95% CI = 8.4–9.9) among men and 10.3% (95% CI = 9.1–11.4) among women. Highest excess fatality was observed in the oldest age group in both genders. Reoperation was needed in 19.4% (n = 1588) of patients. Older age but not comorbidity burden or other patient-related characteristics were associated with increased risk for reoperation. The overall case-fatality and need for reoperations declined during the study era. Comorbidities should be considered when care and follow-up are planned in patients with cSDH. Our findings underpin the perception that the disease is more dangerous than previously thought and causes mortality in all exposed age groups: even a minor burden of comorbidities can be fatal in the post-operative period.
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Affiliation(s)
- Jussi P Posti
- Neurocenter, Department of Neurosurgery and Turku Brain Injury Center, Turku University Hospital and University of Turku, P.O. Box 52, 20521, Turku, Finland.
| | - Teemu M Luoto
- Department of Neurosurgery, Tampere University Hospital and Tampere University, Tampere, Finland
| | - Jussi O T Sipilä
- Clinical Neurosciences, University of Turku, Turku, Finland.,Department of Neurology, Siun Sote, North Karelia Central Hospital, Joensuu, Finland
| | - Päivi Rautava
- Clinical Research Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Ville Kytö
- Heart Centre and Center for Population Health Research, Turku University Hospital and University of Turku, Turku, Finland.,Research Center of Applied and Preventive Cardiovascular Medicine, University of Turku, Turku, Finland.,Center for Population Health Research, Turku University Hospital and University of Turku, Turku, Finland.,Administative Center, Hospital District of Southwest Finland, Turku, Finland
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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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Di Cristofori A, Remida P, Patassini M, Piergallini L, Buonanno R, Bruno R, Carrabba G, Pavesi G, Iaccarino C, Giussani CG. Middle meningeal artery embolization for chronic subdural hematomas. A systematic review of the literature focused on indications, technical aspects, and future possible perspectives. Surg Neurol Int 2022; 13:94. [PMID: 35399896 PMCID: PMC8986643 DOI: 10.25259/sni_911_2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 02/14/2022] [Indexed: 12/20/2022] Open
Abstract
Background: Chronic subdural hematoma (CSDH) is one of the most common neurosurgical diseases that affect elderly and fragile patients and as a consequence, management can be challenging. Surgery represents the standard treatment; however, alternative options are under investigation. Middle meningeal artery (MMA) embolization is considered a minimally invasive treatment although with poor evidence. In this review, we tried to summarize the findings about MMA embolization as a treatment for a CSDH to provide a useful guidance for clinical practice and for future speculative aspects. Methods: Literature review on PubMed until March 2021 was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement. We conducted a research on PubMed with a various combinations of the keywords “CSDH” and “middle meningeal artery” and “embolization,” “refractory subdural hematoma,” and then we reviewed the references of the relevant studies as additional source of eligible articles. Results: Among the 35 studies eligible for this review, 22 were case series, 11 were case reports, one was a technical note, and 1 was a randomized trial. A total of 746 patients were found in the literature. Failure rate of MMA embolization was between 3.9 and 8.9% of the cases according the indication to treat CSDH (upfront vs. after surgery). Conclusion: The global impression deriving from the data available and the literature is that MMA embolization is a safe procedure with very low complications and with a low failure rate, both when associated with surgery or in case of a standalone treatment.
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Affiliation(s)
- Andrea Di Cristofori
- Unit of Neurosurgery, Azienda Socio SanitariaTerritoriale - Monza, Ospedale San Gerardo,
| | - Paolo Remida
- Unit of Neuroradiology, Azienda Socio Sanitaria Territoriale - Monza, Ospedale San Gerardo, Monza,
| | - Mirko Patassini
- Unit of Neuroradiology, Azienda Socio Sanitaria Territoriale - Monza, Ospedale San Gerardo, Monza,
| | - Lorenzo Piergallini
- Unit of Neuroradiology, Azienda Socio Sanitaria Territoriale - Monza, Ospedale San Gerardo, Monza,
| | - Raffaella Buonanno
- Unit of Neurosurgery, Azienda Socio SanitariaTerritoriale - Monza, Ospedale San Gerardo,
- Unit of Neurosurgery, School of Medicine and Surgery, Department of Medicine and Surgery, Università degli Studi Milano Bicocca, Milan,
| | - Raffaele Bruno
- Unit of Neurosurgery, Azienda Socio SanitariaTerritoriale - Monza, Ospedale San Gerardo,
- Unit of Neurosurgery, School of Medicine and Surgery, Department of Medicine and Surgery, Università degli Studi Milano Bicocca, Milan,
| | - Giorgio Carrabba
- Unit of Neurosurgery, Azienda Socio SanitariaTerritoriale - Monza, Ospedale San Gerardo,
- Unit of Neurosurgery, School of Medicine and Surgery, Department of Medicine and Surgery, Università degli Studi Milano Bicocca, Milan,
| | - Giacomo Pavesi
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia,
- Neurosurgery Division, University Hospital of Modena, Modena, Italy
| | - Corrado Iaccarino
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia,
- Neurosurgery Division, University Hospital of Modena, Modena, Italy
| | - Carlo Giorgio Giussani
- Unit of Neurosurgery, Azienda Socio SanitariaTerritoriale - Monza, Ospedale San Gerardo,
- Unit of Neurosurgery, School of Medicine and Surgery, Department of Medicine and Surgery, Università degli Studi Milano Bicocca, Milan,
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Martinez-Escalante L, Martínez-Guerrero B, Ortega-Valencia R. Brain stem hemorrhage after burr hole drainage of chronic subdural hematoma; report of two cases. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2021.101386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Mainka N, Borger V, Hadjiathanasiou A, Hamed M, Potthoff AL, Vatter H, Schuss P, Schneider M. Dehydration Status at Admission Predicts Recurrence in Patients with Traumatic Chronic Subdural Hematoma. J Clin Med 2022; 11:jcm11051178. [PMID: 35268269 PMCID: PMC8911199 DOI: 10.3390/jcm11051178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 02/07/2022] [Accepted: 02/19/2022] [Indexed: 12/29/2022] Open
Abstract
Objective: There remains a significant risk of chronic subdural hematoma (CSDH) recurring after treatment. Patient-related predictors and surgical procedures have been investigated in many studies. In contrast, the literature remains scant on reports of the potential impact of dehydration on the admission of affected patients and on the CSDH recurrence rate. Methods: All consecutively admitted patients with CSDH and surgical treatment at the authors’ institution between 2015 and 2019 were retrospectively identified. Dehydration was assessed as a blood urea/creatinine (U/Cr) ratio > 80. The association between dehydration on admission and postoperative complication rates, in-hospital mortality, and recurrence of CSDH, with the need for additional surgical treatment, was further analyzed. Results: A total of 265 patients with CSDH requiring surgery were identified. In 32 patients (12%), further surgery was necessary due to the recurrence of CSDH. It was found that 9 of the 265 patients with CSDH (3%) suffered from dehydration at the time of admission. Multivariate analysis revealed diabetes mellitus (p = 0.02, OR 2.7, 95% CI 1.2−6.5), a preoperative midline shift > 5 mm (p = 0.003, OR 3.3, 95% CI 1.5−7.5) and dehydration on admission (p = 0.002, OR 10.3, 95% CI 2.4−44.1) as significant and independent predictors for the development of CSDH recurrence that requires surgery. Conclusion: the present findings indicate that dehydration on admission appears to be an independent predictor for CSDH recurrence that requires surgery.
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Affiliation(s)
- Niklas Mainka
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany; (N.M.); (V.B.); (A.H.); (M.H.); (A.-L.P.); (H.V.); (P.S.)
| | - Valeri Borger
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany; (N.M.); (V.B.); (A.H.); (M.H.); (A.-L.P.); (H.V.); (P.S.)
| | - Alexis Hadjiathanasiou
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany; (N.M.); (V.B.); (A.H.); (M.H.); (A.-L.P.); (H.V.); (P.S.)
- Department of Neurosurgery, BG Klinikum Unfallkrankenhaus Berlin, 12683 Berlin, Germany
| | - Motaz Hamed
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany; (N.M.); (V.B.); (A.H.); (M.H.); (A.-L.P.); (H.V.); (P.S.)
| | - Anna-Laura Potthoff
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany; (N.M.); (V.B.); (A.H.); (M.H.); (A.-L.P.); (H.V.); (P.S.)
| | - Hartmut Vatter
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany; (N.M.); (V.B.); (A.H.); (M.H.); (A.-L.P.); (H.V.); (P.S.)
| | - Patrick Schuss
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany; (N.M.); (V.B.); (A.H.); (M.H.); (A.-L.P.); (H.V.); (P.S.)
- Department of Neurosurgery, BG Klinikum Unfallkrankenhaus Berlin, 12683 Berlin, Germany
| | - Matthias Schneider
- Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany; (N.M.); (V.B.); (A.H.); (M.H.); (A.-L.P.); (H.V.); (P.S.)
- Correspondence: ; Tel.: +49-228-265-16518
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Blaauw J, Meelis GA, Jacobs B, Gaag NA, Jellema K, Kho KH, Groen RJ, Naalt J, Lingsma HF, den Hertog HM. Presenting symptoms and functional outcome of chronic subdural hematoma patients. Acta Neurol Scand 2022; 145:38-46. [PMID: 34448196 DOI: 10.1111/ane.13518] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 07/23/2021] [Accepted: 08/04/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND Patients with chronic subdural hematoma (CSDH) can present with a variety of signs and symptoms. The relationship of these signs and symptoms with functional outcome is unknown. Knowledge of these associations might aid clinicians in the choice to initiate treatment and may allow them to better inform patients on expected outcomes. OBJECTIVE To investigate if presenting signs and symptoms influence functional outcome in patients with CSDH. METHODS We conducted a retrospective analysis of consecutive CSDH patients in three hospitals. Glasgow Outcome Scale Extended (GOS-E) scores were obtained from the first follow-up visit after treatment. An ordinal multivariable regression analysis was performed, to assess the relationship between the different signs and symptoms on the one hand and functional outcome on the other adjusted for potential confounders. RESULTS We included 1,307 patients, of whom 958 (73%) were male and mean age was 74 (SD ± 11) years. Cognitive complaints were associated with lower GOS-E scores at follow-up (aOR 0.7, 95% CI: 0.5 - 0.8) Headache and higher Glasgow Coma Scale (GCS) scores were associated with higher GOS-E scores. (aOR 1.9, 95% CI: 1.5-2.3 and aOR 1.3, 95% CI: 1.2-1.4). CONCLUSION Cognitive complaints are independently associated with worse functional outcome, whereas headache and higher GCS scores are associated with better outcome. The increased probability of unfavorable outcome in patients with CSDH who present with cognitive complaints favors a more prominent place of assessing cognitive status at diagnosis.
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Affiliation(s)
- Jurre Blaauw
- Department of Neurology University of GroningenUniversity Medical Center Groningen Groningen The Netherlands
- Center for Medical Decision Sciences Department of Public Health Erasmus Medical Center Rotterdam The Netherlands
| | | | - Bram Jacobs
- Department of Neurology University of GroningenUniversity Medical Center Groningen Groningen The Netherlands
| | - Niels A. Gaag
- University Neurosurgical Center Holland (UNCHLeiden University Medical CenterHaaglanden Medical Center & Haga teaching hospitalLeiden & The Hague The Hague The Netherlands
| | - Korné Jellema
- Department of Neurology Haaglanden Medical Centre The Hague The Netherlands
| | - Kuan H. Kho
- Department of Neurosurgery Medisch Spectrum Twente Enschede The Netherlands
| | - Rob J.M. Groen
- Department of Neurosurgery University Medical Center Groningen Groningen The Netherlands
| | - Joukje Naalt
- Department of Neurology University of GroningenUniversity Medical Center Groningen Groningen The Netherlands
| | - Hester F. Lingsma
- Center for Medical Decision Sciences Department of Public Health Erasmus Medical Center Rotterdam The Netherlands
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Tariq J, Bhatti SN. Adjunctive postoperative course of dexamethasone in chronic subdural hematoma: Effect on surgical outcome. Pak J Med Sci 2021; 37:1877-1882. [PMID: 34912411 PMCID: PMC8613023 DOI: 10.12669/pjms.37.7.3374] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 02/05/2021] [Accepted: 07/15/2021] [Indexed: 11/24/2022] Open
Abstract
Objectives: To compare the effect of burrhole craniostomy with and without a postoperative course of dexamethasone on recurrence rate of chronic subdural hematoma (CSDH). Methods: The study was conducted at the Department of Neurosurgery, Pakistan Institute of Medical Sciences, Islamabad, from September 2017 till May 2018. Adult patients diagnosed with CSDH and advised burrhole craniostomy were enrolled in this prospective randomized controlled trial. Participants were randomized into Group-1 (receiving two weeks dexamethasone), and Group-2 (no dexamethasone). Clinical assessment and Brain CT were done preoperatively, second postoperative day, sixth and twelfth postoperative week, with outcome assessed at twelfth postoperative week. Complications of treatment and recurrence rate were recorded. Results: Ninety-two (n=92, 46 in each group) patients were enrolled. Improvement in neurological (95.7% vs 93.5%; P=0.646) and radiological outcome (95.7% vs 93.5%; P=0.646) was similar in both groups. Complication rate was higher in Group-1 but not significantly different (58.7% vs 43.5%; P=0.535). Most frequent complication was pneumocephalus, with mortality rate equal (n=one). Recurrence was observed in 2.2% (n=1/46) patients in Group-1 and 4.3% (n=2/46) in Group-2 (P=0.557), which was not statistically significant. Conclusions: Neurological and radiological outcome, and mortality rates were similar in both groups. The recurrence rate was lower and complications slightly higher in Group-1 but these were not statistically significant.
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Affiliation(s)
- Jibran Tariq
- Jibran Tariq, MS. Senior Registrar, Department of Surgery, Peshawar Institute of Medical Sciences, Pak International Medical College, Peshawar, Pakistan
| | - Sajid Nazir Bhatti
- Sajid Nazir Bhatti, FCPS/MS. Head of Department, Department of Neurosurgery, Pakistan Institute of Medical Sciences, Shaheed Zulfiqar Ali Bhutto Medical University, Islamabad, Pakistan
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Colamaria A, Sacco M, Iodice S, Fochi NP, Carbone F. Cerebrospinal fluid leak as a driving factor in chronic subdural hematoma formation: A histological study. Surg Neurol Int 2021; 12:578. [PMID: 34877064 PMCID: PMC8645496 DOI: 10.25259/sni_950_2021] [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: 09/20/2021] [Accepted: 10/27/2021] [Indexed: 11/20/2022] Open
Abstract
Background: Chronic subdural hematoma (CSDH) represents the most common neurosurgical disease. Given the demographic shift toward an aging population, the overall incidence of this condition is increasing. Nevertheless, clarity in the pathophysiological process is yet to be made. Several etiological mechanisms have been proposed to initiate and consequently promote fluid collection in the subdural space. Traumatic injury of the bridging veins has long been considered the primum movens of the pathology but increasing evidence shows that trauma is not the only factor involved. Along with recent advances we sought to understand the role of the cerebrospinal fluid (CSF) in the buildup of the intense inflammatory reaction that characterizes CSDH. Methods: In the present study, we examined histological features of reactive membranes secondary to extracranial CSF leakage with CSDH-related membranes. Similarity and differences between the specimens were examined by means of light microscopy. Results: Histological similarities were consistently found between CSDH membranes and reactive membranes secondary to CSF leakage in the extracranial space. Activated histiocytes were highlighted in all specimens along with an intense inflammatory reaction. Conclusion: CSDH is most likely the result of a complex interaction among different pathophysiological events resulting from both traumatic and inflammatory etiologies. In the present work, we highlight how CSF leakage could be an early factor that leads to a cascade of events that culminates in CSDH formation.
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Affiliation(s)
| | - Matteo Sacco
- Department of Neurosurgery, "Riuniti" Hospital, Foggia, Italy
| | - Savino Iodice
- Department of Neurosurgery, "Riuniti" Hospital, Foggia, Italy
| | - Nicola Pio Fochi
- Department of Neurosurgery, University of Foggia, Foggia, Puglia, Italy
| | - Francesco Carbone
- Department of Neurosurgery, University of Foggia, Foggia, Puglia, Italy
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Yamaguchi I, Kanematsu Y, Mizobuchi Y, Tada Y, Miyamoto T, Sogabe S, Ishihara M, Kagusa H, Yamamoto Y, Matsuda T, Kitazato KT, Okayama Y, Takagi Y. Chronic subdural hematoma associated with dural metastasis leads to early recurrence and death: A single-institute, retrospective cohort study. J Clin Neurosci 2021; 94:244-249. [PMID: 34863446 DOI: 10.1016/j.jocn.2021.10.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 10/18/2021] [Accepted: 10/26/2021] [Indexed: 11/19/2022]
Abstract
The prevalence of chronic subdural hematoma (CSDH) associated with dural metastasis is uncertain, and appropriate treatment strategies have not been established. This study aimed to investigate the characteristics of and appropriate treatment strategies for CSDH associated with dural metastasis. We retrospectively reviewed the charts of 214 patients who underwent surgery for CSDH. The patients were divided into the dural metastasis group (DMG; n = 5, 2.3%) and no dural metastasis group (No-DMG; n = 209, 97.3%). Patient characteristics, treatment, and outcomes were compared between the two groups. Active cancer was detected in 31 out of 214 patients, 5 of whom (16.1%) had dural metastasis. In-hospital death (80.0% vs. 0%; p < 0.001) and recurrence within 14 days (80.0% vs. 2.9%; p < 0.001) and 60 days (80.0% vs. 13.9%; p = 0.002) were significantly prevalent in the DMG. All patients in the DMG developed subdural hematoma re-accumulation requiring emergent surgery because of brain herniation, and patients in the DMG had significantly worse recurrence-free survival (p < 0.001). This relationship remained significant (p < 0.001) even when the analysis was limited to the active cancer cohort (n = 31). CSDH associated with dural metastasis leads to early recurrence and death because of the difficulty in controlling subdural hematoma re-accumulation by common drainage procedures. Depending on the primary cancer status, withdrawal of active treatment and change to palliative care should be discussed after diagnosing CSDH associated with dural metastasis.
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Affiliation(s)
- Izumi Yamaguchi
- Department of Neurosurgery, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan.
| | - Yasuhisa Kanematsu
- Department of Neurosurgery, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Yoshifumi Mizobuchi
- Department of Neurosurgery, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Yoshiteru Tada
- Department of Neurosurgery, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Takeshi Miyamoto
- Department of Neurosurgery, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Shu Sogabe
- Department of Neurosurgery, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Manabu Ishihara
- Department of Neurosurgery, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Hiroshi Kagusa
- Department of Neurosurgery, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Yoko Yamamoto
- Department of Neurosurgery, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Taku Matsuda
- Department of Neurosurgery, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Keiko T Kitazato
- Department of Neurosurgery, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Yoshihiro Okayama
- Clinical Trial Center for Development Therapeutics, Tokushima University Hospital, Tokushima, Japan
| | - Yasushi Takagi
- Department of Neurosurgery, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
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Erdogan B, Is M, Tural Emon S, Ceman D, Orakdogen M, Engin T. Retrospective analysis of 195 surgically treated cases of chronic subdural hematoma. Int J Clin Pract 2021; 75:e15014. [PMID: 34808025 DOI: 10.1111/ijcp.15014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 04/17/2021] [Accepted: 11/19/2021] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION The incidence of chronic subdural hematoma (CSDH) is increasing. This study evaluates the etiologic causes and findings of CSDH and compared unilateral CSDH with bilateral CSDH. This study aims to draw attention to this increasingly prevalent condition. METHODS We retrospectively analysed 195 surgically treated cases of CSDH in our clinic between 2008 and 2018. RESULTS The average age of the patients was 65.7 ± 19.6 years. The most common symptom was headache (53.3%). The case background was the use of anticoagulant (37.9%), head trauma (34.3%). The hematomas were 28.7% right side, 44.6% left side, and 26.7% bilateral. The mean Glasgow Coma Score (GCS) was 13.4 ± 2.9, early postop 13.8 ± 2.5, and late postop was 14.6 ± 1.1. Postoperative complications included acute subdural hematoma (5.1%), cerebral infarction (1.5%), wound infection (0.5%) and others (13.3%). Re-expansion of the brain were statistically significantly less frequent and impaired consciousness, anticoagulant use, early and late postop thickness were statistically significantly more frequent in patients with bilateral CSDH. CONCLUSIONS CSDH is seen more patients of advanced age, those who use anticoagulants, patients with hypertension and diabetes and in patients with a history of head trauma. Prognosis is worse in bilateral CSDH. We estimate that the incidence of CSDH will go up in the future.
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Affiliation(s)
- Baris Erdogan
- Department of Neurosurgery, Sanliurfa Training and Research Hospital, Şanlıurfa, Turkey
| | - Merih Is
- Department of Neurosurgery, University of Health Sciences Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | - Selin Tural Emon
- Department of Neurosurgery, University of Health Sciences Haydarpaşa Numune Training and Research Hospital, Istanbul, Turkey
| | - Duygu Ceman
- Department of Neurosurgery, Sancaktepe Şehit Prof. Dr. İlhan Varank Training and Research Hospital, Istanbul, Turkey
| | - Metin Orakdogen
- Department of Neurosurgery, University of Trakya, Edirne, Turkey
| | - Taner Engin
- Department of Neurosurgery, University of Health Sciences Mehmet Akif İnan Training and Research Hospital, Istanbul, Turkey
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41
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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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Désir LL, D'Amico R, Link T, Silva D, Ellis JA, Doron O, Langer DJ, Ortiz R, Serulle Y. Middle Meningeal Artery Embolization and the Treatment of a Chronic Subdural Hematoma. Cureus 2021; 13:e18868. [PMID: 34754700 PMCID: PMC8570051 DOI: 10.7759/cureus.18868] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2021] [Indexed: 11/18/2022] Open
Abstract
Chronic subdural hematoma (cSDH) is a common pathology that typically affects the elderly. It is believed to occur due to injury to the dural border cells, which creates an inflammation/proliferation reaction. Ineffective repair leads to the formation of a new external layer of cells and fragile capillaries, which damage easily and can worsen the condition. Conventionally, asymptomatic cSDH is managed by observation, and symptomatic cases are treated by surgical evacuation. Unfortunately, recurrence rates of the SDH following surgical evacuation can be high. One treatment option for SDH involves embolization of the middle meningeal artery (MMA). The MMA provides blood supply to the dura mater and feeds the membrane capillaries covering the SDH. MMA embolization blocks the blood flow to this system and can promote hematoma resolution. In this paper, we review the existing literature on MMA embolization and discuss the underlying pathophysiology of cSDH.
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Affiliation(s)
- Likowsky L Désir
- Department of Neurological Surgery, Lenox Hill Hospital, New York City, USA
| | - Randy D'Amico
- Department of Neurological Surgery, Lenox Hill Hospital, New York City, USA
| | - Thomas Link
- Department of Neurological Surgery, Lenox Hill Hospital, New York City, USA
| | - Danilo Silva
- Department of Neurological Surgery, Lenox Hill Hospital, New York City, USA
| | - Jason A Ellis
- Department of Neurological Surgery, Lenox Hill Hospital, New York City, USA
| | - Omer Doron
- Department of Neurological Surgery, Lenox Hill Hospital, New York City, USA
| | - David J Langer
- Department of Neurological Surgery, Lenox Hill Hospital, New York City, USA
| | - Rafael Ortiz
- Department of Neurological Surgery, Lenox Hill Hospital, New York City, USA
| | - Yafell Serulle
- Department of Neurological Surgery, Lenox Hill Hospital, New York City, USA
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43
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Oh HJ, Seo Y, Choo YH, Kim YI, Kim KH, Kwon SM, Lee MH, Chong K. Clinical Characteristics and Current Managements for Patients with Chronic Subdural Hematoma : A Retrospective Multicenter Pilot Study in the Republic of Korea. J Korean Neurosurg Soc 2021; 65:255-268. [PMID: 34727680 PMCID: PMC8918242 DOI: 10.3340/jkns.2021.0138] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 07/21/2021] [Indexed: 11/27/2022] Open
Abstract
Objective Chronic subdural hematoma (CSDH) is a common disease in neurosurgical departments, but optimal perioperative management guidelines have not yet been established. We aimed to assess the current clinical management and outcomes for CSDH patients and identify prognostic factors for CSDH recurrence.
Methods We enrolled a total of 293 consecutive patients with CSDH who underwent burr hole craniostomy at seven institutions in 2018. Clinical and surgery-related characteristics and surgical outcomes were analyzed. The cohort included 208 men and 85 women.
Results The median patient age was 75 years. Antithrombotic agents were prescribed to 105 patients. History of head trauma was identified in 59% of patients. Two hundred twenty-seven of 293 patients (77.5%) had unilateral hematoma and 46.1% had a homogenous hematoma type. About 70% of patients underwent surgery under general anesthesia, and 74.7% underwent a single burr hole craniostomy surgery. Recurrence requiring surgery was observed in 17 of 293 patients (5.8%), with a median of 32 days to recurrence. The postoperative complication rate was 4.1%. In multivariate analysis, factors associated with CSDH recurrence were separated hematoma type (odds ratio, 3.906; p=0.017) and patient who underwent surgery under general anesthesia had less recurrence (odds ratio, 0.277; p=0.017).
Conclusion This is the first retrospective multicenter generalized cohort pilot study in the Republic of Korea as a first step towards the development of Korean clinical practice guidelines for CSDH. The type of hematoma and anesthesia was associated with CSDH recurrence. Although the detailed surgical method differs depending on the institution, the surgical treatment of CSDH was effective. Further studies may establish appropriate management guidelines to minimize CSDH recurrence.
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Affiliation(s)
- Hyuk-Jin Oh
- Neurotrauma Clinical Practice Guidelines Committee of the Korean Neurotraumatology Society (KNTS-NCPGC), Seoul, Korea.,Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, College of Medicine, Soonchunhyang University, Cheonan, Korea
| | - Youngbeom Seo
- Neurotrauma Clinical Practice Guidelines Committee of the Korean Neurotraumatology Society (KNTS-NCPGC), Seoul, Korea.,Department of Neurosurgery, Yeungnam University Hospital, Yeungnam Universtiy College of Medicine, Daegu, Korea
| | - Yoon-Hee Choo
- Department of Neurosurgery, Yeungnam University Hospital, Yeungnam Universtiy College of Medicine, Daegu, Korea.,Department of Intensive Care, Seoul National University Hospital, Seoul, Korea
| | - Young Il Kim
- Neurotrauma Clinical Practice Guidelines Committee of the Korean Neurotraumatology Society (KNTS-NCPGC), Seoul, Korea.,Department of Neurosurgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kyung Hwan Kim
- Neurotrauma Clinical Practice Guidelines Committee of the Korean Neurotraumatology Society (KNTS-NCPGC), Seoul, Korea.,Department of Neurosurgery, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Sae Min Kwon
- Neurotrauma Clinical Practice Guidelines Committee of the Korean Neurotraumatology Society (KNTS-NCPGC), Seoul, Korea.,Department of Neurosurgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Min Ho Lee
- Neurotrauma Clinical Practice Guidelines Committee of the Korean Neurotraumatology Society (KNTS-NCPGC), Seoul, Korea.,Department of Neurosurgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kyuha Chong
- Neurotrauma Clinical Practice Guidelines Committee of the Korean Neurotraumatology Society (KNTS-NCPGC), Seoul, Korea.,Department of Neurosurgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea.,Neurological Institute, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
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Scerrati A, Visani J, Ricciardi L, Dones F, Rustemi O, Cavallo MA, De Bonis P. To drill or not to drill, that is the question: nonsurgical treatment of chronic subdural hematoma in the elderly. A systematic review. Neurosurg Focus 2021; 49:E7. [PMID: 33002869 DOI: 10.3171/2020.7.focus20237] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 07/21/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Chronic subdural hematoma (CSDH) is one of the most common neurosurgical pathologies, typically affecting the elderly. Its incidence is expected to grow along with the aging population. Surgical drainage represents the treatment of choice; however, postoperative complications and the rate of recurrence are not negligible. For this reason, nonsurgical alternatives (such as middle meningeal artery embolization, steroids, or tranexamic acid administration) are gaining popularity worldwide and need to be carefully evaluated, especially in the elderly population. METHODS The authors performed a systematic review according to PRISMA criteria of the studies analyzing the nonsurgical strategies for CSDHs. They collected all papers in the English language published between 1990 and 2019 by searching different medical databases. The chosen keywords were "chronic subdural hematoma," "conservative treatment/management," "pharmacological treatment," "non-surgical," "tranexamic acid," "dexamethasone," "corticosteroid," "glucocorticoid," "middle meningeal artery," "endovascular treatment," and "embolization." RESULTS The authors ultimately collected 15 articles regarding the pharmacological management of CSDHs matching the criteria, and 14 papers included the endovascular treatment. CONCLUSIONS The results showed that surgery still represents the mainstay in cases of symptomatic patients with large CSDHs; however, adjuvant and alternative therapies can be effective and safe in a carefully selected population. Their inclusion in new guidelines is advisable.
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Affiliation(s)
- Alba Scerrati
- 1Department of Morphology, Anatomy and Experimental Medicine, University of Ferrara.,2Department of Neurosurgery, Sant'Anna University Hospital, Ferrara
| | - Jacopo Visani
- 2Department of Neurosurgery, Sant'Anna University Hospital, Ferrara
| | - Luca Ricciardi
- 3Department of Neurosurgery, Pia Fondazione di Culto e Religione Cardinal G. Panico, Tricase, Lecce; and
| | - Flavia Dones
- 2Department of Neurosurgery, Sant'Anna University Hospital, Ferrara
| | - Oriela Rustemi
- 4Department of Neurosurgery, San Bortolo Hospital, Vicenza, Italy
| | - Michele Alessandro Cavallo
- 1Department of Morphology, Anatomy and Experimental Medicine, University of Ferrara.,2Department of Neurosurgery, Sant'Anna University Hospital, Ferrara
| | - Pasquale De Bonis
- 1Department of Morphology, Anatomy and Experimental Medicine, University of Ferrara.,2Department of Neurosurgery, Sant'Anna University Hospital, Ferrara
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45
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Yang L, Li N, Yang L, Wang D, Qiang S, Zhao Z. Atorvastatin-Induced Absorption of Chronic Subdural Hematoma Is Partially Attributed to the Polarization of Macrophages. J Mol Neurosci 2021; 72:565-573. [PMID: 34569007 DOI: 10.1007/s12031-021-01910-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 09/02/2021] [Indexed: 11/25/2022]
Abstract
As one of the main types of secondary craniocerebral injury, the onset, progression, and prognosis of chronic subdural hematoma (CSDH) are closely related to the local inflammation of intracranial hematoma. Atorvastatin is reported to be effective in the conservative treatment of CSDH. This study aimed to clarify whether atorvastatin regulated the inflammatory responses in CSDH by interfering with the function of macrophages. The rat CSDH model was prepared by repeated intracranial blood injection with velocity gradient, and MRI was applied to calculate the intracranial hematoma volume. Changes in rat nerve functions were evaluated by foot-fault and Morris water maze tests. Flow cytometry was applied to detect the number of total macrophages and the percentage of M1 or M2 macrophages. The expression of inflammatory factors was examined by ELISA and western blot. Western bolt was applied to detect the expression of proteins involved in the colony-stimulating factor 1 receptor (CSF-1R) signaling pathway. Our results showed that atorvastatin significantly accelerated the absorption of hematoma and improved the nerve functions of CSDH rats. In addition, atorvastatin treatment effectively suppressed the expression of TNF-α, IL-6, and IL-8 and promoted the expression of IL-10. The total number of macrophages was decreased, and the percentage of M2 macrophages was increased in the intracranial hematoma following atorvastatin treatment. Furthermore, atorvastatin increased the levels of M2-related genes and surface markers in BMDMs stimulated by lipopolysaccharides and IFNγ, and activated the CSF-1R signaling pathway. In conclusion, our study shows that atorvastatin could alleviate the symptoms of CSDH and promote hematoma ablation by polarizing macrophages to M2 type and regulating the inflammatory responses.
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Affiliation(s)
- Liang Yang
- Department of Neurosurgery, the Second Hospital of Hebei Medical University, No. 215 Heping West Road, Shijiazhuang 050000, Hebei, China
| | - Nan Li
- Department of Gynecology, the Second Hospital of Hebei Medical University, No. 215 Heping West Road, Shijiazhuang 050000, Hebei, China
| | - Lijun Yang
- Department of Neurosurgery, the Second Hospital of Hebei Medical University, No. 215 Heping West Road, Shijiazhuang 050000, Hebei, China
| | - Dong Wang
- Department of Neurosurgery, Tianjin Medical University General Hospital, No. 154 Anshan Road, Tianjin, 300052, China
| | - Shuke Qiang
- Department of Neurosurgery, the Second Hospital of Hebei Medical University, No. 215 Heping West Road, Shijiazhuang 050000, Hebei, China
| | - Zongmao Zhao
- Department of Neurosurgery, the Second Hospital of Hebei Medical University, No. 215 Heping West Road, Shijiazhuang 050000, Hebei, China.
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46
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Jain V, Remley W, Mohan A, Leone EL, Taneja S, Busl K, Almeida L. Nonepileptic, Stereotypical, and Intermittent Symptoms After Subdural Hematoma Evacuation. Cureus 2021; 13:e18361. [PMID: 34725611 PMCID: PMC8555749 DOI: 10.7759/cureus.18361] [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] [Accepted: 09/27/2021] [Indexed: 11/30/2022] Open
Abstract
Transient neurological deficits can occur in the setting of subdural hemorrhages with subsequent unremarkable electrodiagnostic and radiological evaluation. This scenario is rare and can be difficult for physicians to interpret. These transient neurological deficits are thought to result from relative ischemia, secondary to a lesser-known concept known as cortical spreading depolarization. These transient neurological deficits are thought to result from relative ischemia, secondary to a lesser-known concept known as cortical spreading depolarization, which may present clinically as nonepileptic, stereotypical, and intermittent symptoms (NESIS). In these instances, patients are often misdiagnosed as epileptics and committed to long-term antiseizure drugs. We present a 51-year-old patient developing acute global aphasia following the evacuation of a subdural hematoma, with no significant findings on laboratory, microbiological, electrodiagnostic, or radiological evaluation. The patient experienced spontaneous improvement and returned to baseline in the subsequent weeks. Increased awareness of NESIS as a cortical spreading depolarization phenomenon can improve patient care and prevent both unnecessary, extended medical evaluations and therapeutic trials.
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Affiliation(s)
- Varun Jain
- Neurology, University of Florida, Gainesville, USA
| | - William Remley
- Neurology, Lake Erie College of Osteopathic Medicine, Jacksonville, USA
| | - Arvind Mohan
- Neurosurgery, University of Florida, Gainesville, USA
| | - Emma L Leone
- Neurology, University of Florida, Gainesville, USA
| | - Srishti Taneja
- Neurology, Avalon University School of Medicine, Youngstown, USA
| | - Katharina Busl
- Neurocritical Care, University of Florida, Gainesville, USA
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47
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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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48
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Pan Z, Bao J, Wei S. Efficacy of the Direct Aspiration-Irrigation Maneuver for the Treatment of Chronic Subdural Hematoma: A Single Hospital's Experience. Cureus 2021; 13:e16231. [PMID: 34268061 PMCID: PMC8262522 DOI: 10.7759/cureus.16231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2021] [Indexed: 11/05/2022] Open
Abstract
Objective The traditional methods for managing symptomatic chronic subdural hematoma (CSDH) at our hospital include evacuation via single burr-hole irrigation with continuous closed subdural drainage (SBID). The single burr-hole aspiration and irrigation technique with continuous closed subdural drainage (SBAID) is an attractive alternative method. The goal of this study was to evaluate the radiographic and clinical outcomes of SBAID compared with traditional SBID methods. Methods A database of 51 CSDH patients treated with the SBAID method and 35 CSDH patients treated with the SBID method was compiled, and a retrospective chart review was performed. Information regarding demographics, comorbidities, presenting symptoms, and outcomes were collected. Predictors of recurrence requiring reoperation and other outcomes were analyzed. Results Compared to the patients in the SBID group, the patients in the SBAID group had a shorter mean duration of surgery (56.6±5.6 minutes vs 59.5±4.8 minutes, respectively, P=0.02); a shorter mean interval from procedure to discharge (6.2±1.2 days vs 6.8±1.3 days, respectively, P=0.046); no significant difference in preoperative hematoma volume (106.4±21.7 cm3 vs 101.3±16.3 cm3, respectively, P=0.25); and a smaller subdural space volume 48 hours after the operation (43.6±7.4 cm3 vs 47.4±9.1 cm3, respectively, P=0.03). In addition, symptomatic hematoma recurrence developed in one patient in the SBAID group and five patients in the SBID group (P=0.03). The in-hospital mortality rates of the SBAID and SBID groups were 2% (1 of 51) and 6% (2 of 35), respectively; this difference was not statistically significant (P=0.35). Conclusions The SBAID method results in a remarkably low recurrence rate and good outcomes. This method should be considered for patients presenting with symptomatic CSDHs.
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Affiliation(s)
- Zhenjiang Pan
- Neurosurgery, Shidong Hospital of Yangpu District, Shanghai, CHN
| | - Jing Bao
- Neurosurgery, Shidong Hospital of Yangpu District, Shanghai, CHN
| | - Shepeng Wei
- Neurosurgery, Shidong Hospital of Yangpu District, Shanghai, CHN
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49
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A matter of frailty: the modified Subdural Hematoma in the Elderly (mSHE) score. Neurosurg Rev 2021; 45:701-708. [PMID: 34231088 PMCID: PMC8827338 DOI: 10.1007/s10143-021-01586-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 05/05/2021] [Accepted: 06/14/2021] [Indexed: 10/27/2022]
Abstract
The Subdural Hematoma in the Elderly (SHE) score was developed as a model to predict 30-day mortality from acute, chronic, and mixed subdural hematoma in the elderly population after minor or no trauma. Emerging evidence suggests frailty to be predictive of mortality and morbidity in the elderly. In this study, we aim to externally validate the SHE for chronic subdural hematoma (CSDH) alone, and we hypothesize that the incorporation of frailty into the SHE may increase its predictive power. A retrospective cohort of elderly patients with CSDH after minor or no trauma being treated at our institution was evaluated with the SHE. Thirty-day mortality and outcome were documented. Patients were assessed with the Clinical Frailty Scale (CFS), which was incorporated into a modified SHE (mSHE). Both the SHE and the mSHE were then assessed in their predictive powers through receiver operating characteristic statistics. We included 168 patients. Most (n = 124, 74%) had a favorable outcome at 30 days. Mortality was low at n = 7, 4%. The SHE failed to predict mortality (AUC = .564, p = .565). Contrarily, the mSHE performed well in both mortality (AUC = .749, p = .026) and outcome (AUC = .862, p < .001). A threshold of mSHE = 3 is predictive of mortality with a sensitivity of 50% and a specificity of 75% and of poor outcome with a sensitivity of 88% and a specificity of 64%. Frailty should be routinely evaluated in elderly individuals, as it can predict outcome and mortality, providing the possibility for medical, surgical, nutritional, cognitive, and physical exercise interventions.
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50
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Zhang JJY, Aw NMY, Tan CH, Lee KS, Chen VHE, Wang S, Dinesh N, Foo ASC, Yang M, Goh CP, Bolem N, Quah BL, Sun IS, Ng ZX, Teo K, Pang BC, Yang EW, Lwin S, Low SW, Yeo TT, Santarius T, Nga VDW. Impact of time to resumption of antithrombotic therapy on outcomes after surgical evacuation of chronic subdural hematoma: A multicenter cohort study. J Clin Neurosci 2021; 89:389-396. [PMID: 34088580 DOI: 10.1016/j.jocn.2021.05.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 05/20/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND The decision to resume antithrombotic therapy after surgical evacuation of chronic subdural hematoma (CSDH) requires judicious weighing of the risk of bleeding against that of thromboembolism. This study aimed to investigate the impact of time to resumption of antithrombotic therapy on outcomes of patients after CSDH drainage. METHODS Data were obtained retrospectively from three tertiary hospitals in Singapore from 2010 to 2017. Outcome measures analyzed were CSDH recurrence and any thromboembolic events. Logistic and Cox regression tests were used to identify associations between time to resumption and outcomes. RESULTS A total of 621 patients underwent 761 CSDH surgeries. Preoperative antithrombotic therapy was used in 139 patients. 110 (79.1%) were on antiplatelets and 35 (25.2%) were on anticoagulants, with six patients (4.3%) being on both antiplatelet and anticoagulant therapy. Antithrombotic therapy was resumed in 84 patients (60.4%) after the surgery. Median time to resumption was 71 days (IQR 29 - 201). Recurrence requiring reoperation occurred in 15 patients (10.8%), of which 12 had recurrence before and three after resumption. Median time to recurrence was 35 days (IQR 27 - 47, range 4 - 82 days). Recurrence rates were similar between patients that were restarted on antithrombotic therapy before and after 14, 21, 28, 42, 56, 70 and 84 days, respectively. Thromboembolic events occurred in 12 patients (8.6%), of which five had the event prior to restarting antithrombosis. CONCLUSIONS Time to antithrombotic resumption did not significantly affect CSDH recurrence. Early resumption of antithrombotic therapy can be safe for patients with a high thromboembolic risk.
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Affiliation(s)
- John J Y Zhang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
| | - Natalie M Y Aw
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Choo Heng Tan
- Division of Neurosurgery, Department of Surgery, National University Hospital, National University Health System, Singapore
| | - Keng Siang Lee
- Bristol Medical School, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Vanessa H E Chen
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Shilin Wang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Nivedh Dinesh
- Division of Neurosurgery, Department of Surgery, National University Hospital, National University Health System, Singapore
| | - Aaron Song Chuan Foo
- Division of Neurosurgery, Department of Surgery, National University Hospital, National University Health System, Singapore
| | - Ming Yang
- Division of Neurosurgery, Department of Surgery, Khoo Teck Puat Hospital, Singapore
| | - Chun Peng Goh
- Division of Neurosurgery, Department of Surgery, National University Hospital, National University Health System, Singapore
| | - Nagarjun Bolem
- Division of Neurosurgery, Department of Surgery, National University Hospital, National University Health System, Singapore
| | - Boon Leong Quah
- Division of Neurosurgery, Department of Surgery, Khoo Teck Puat Hospital, Singapore
| | - Ira Siyang Sun
- Division of Neurosurgery, Department of Surgery, Ng Teng Fong General Hospital, National University Health System, Singapore
| | - Zhi Xu Ng
- Division of Neurosurgery, Department of Surgery, Khoo Teck Puat Hospital, Singapore
| | - Kejia Teo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Neurosurgery, Department of Surgery, National University Hospital, National University Health System, Singapore
| | - Boon Chuan Pang
- Division of Neurosurgery, Department of Surgery, Khoo Teck Puat Hospital, Singapore
| | - Eugene Weiren Yang
- Division of Neurosurgery, Department of Surgery, Khoo Teck Puat Hospital, Singapore
| | - Sein Lwin
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Neurosurgery, Department of Surgery, National University Hospital, National University Health System, Singapore
| | - Shiong Wen Low
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Neurosurgery, Department of Surgery, Ng Teng Fong General Hospital, National University Health System, Singapore
| | - Tseng Tsai Yeo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Neurosurgery, Department of Surgery, National University Hospital, National University Health System, Singapore
| | - Thomas Santarius
- Department of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Vincent D W Nga
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Neurosurgery, Department of Surgery, National University Hospital, National University Health System, Singapore
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