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Nisson PL, Francis JJ, Michel M, Goel K, Patil CG. Extreme-aged patients (≥ 85 years) experience similar outcomes as younger geriatric patients following chronic subdural hematoma evacuation: a matched cohort study. GeroScience 2024; 46:3543-3553. [PMID: 38286851 PMCID: PMC11226415 DOI: 10.1007/s11357-024-01081-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 01/12/2024] [Indexed: 01/31/2024] Open
Abstract
Subdural hematoma (SDH) evacuation represents one of the most frequently performed neurosurgical procedures. Several reports cite a rise in both the age and number of patient's requiring treatment, due in part to an aging population and expanded anticoagulation use. However, limited data and conflicting conclusions exist on extreme-aged geriatric patients (≥ 85 years of age) after undergoing surgery. Patients undergoing SDH evacuation at a tertiary academic medical center between November 2013-December 2021 were retrospectively identified. The study group consisted of patients ≥ 85 years (Group 1) diagnosed with a chronic SDH surgically evacuated. A control group was created matching patients by 70-84 years of age, gender, and anticoagulation use (Group 2). Multiple metrics were evaluated between the two including length-of hospital-stay, tracheostomy/PEG placement, reoperation rate, complications, discharge location, neurological outcome at the time of discharge, and survival. A total of 130 patients were included; 65 in Group 1 and 65 in Group 2. Patient demographics, medical comorbidities, SDH characteristics, international normalized ratio, partial thromboplastin time, and use of blood thinning agents were similar between the two groups. Kaplan Meier survival analysis at one-year was 80% for Group 1 and 76% for Group 2. No significant difference was identified using the log-rank test for equality of survivor functions (p = 0.26). All measured outcomes including GCS at time of discharge, length of stay, rate of reoperations, and neurological outcome were statistically similar between the two groups. Backwards stepwise conditional logistic regression revealed no significant association between poor outcomes at the time of discharge and age. Alternatively, anticoagulation use was found to be associated with poor outcomes (OR 3.55, 95% CI 1.08-11.60; p = 0.036). Several outcome metrics and statistical analyses were used to compare patients ≥ 85 years of age to younger geriatric patients (70-84 years) in a matched cohort study. Adjusting for age group, gender, and anticoagulation use, no significant difference was found between the two groups including neurological outcome at discharge, reoperation rate, and survival.
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Affiliation(s)
- Peyton L Nisson
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - John J Francis
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Michelot Michel
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Keshav Goel
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Chirag G Patil
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Zhang X, Sha Z, Feng D, Wu C, Tian Y, Wang D, Wang J, Jiang R. Establishment and validation of a CT-based prediction model for the good dissolution of mild chronic subdural hematoma with atorvastatin treatment. Neuroradiology 2024; 66:1113-1122. [PMID: 38587561 DOI: 10.1007/s00234-024-03340-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 03/19/2024] [Indexed: 04/09/2024]
Abstract
PURPOSE To develop and validate a prediction model based on imaging data for the prognosis of mild chronic subdural hematoma undergoing atorvastatin treatment. METHODS We developed the prediction model utilizing data from patients diagnosed with CSDH between February 2019 and November 2021. Demographic characteristics, medical history, and hematoma characteristics in non-contrast computed tomography (NCCT) were extracted upon admission to the hospital. To reduce data dimensionality, a backward stepwise regression model was implemented to build a prognostic prediction model. We calculated the area under the receiver operating characteristic curve (AUC) of the prognostic prediction model by a tenfold cross-validation procedure. RESULTS Maximum thickness, volume, mean density, morphology, and kurtosis of the hematoma were identified as the most significant predictors of good hematoma dissolution in mild CSDH patients undergoing atorvastatin treatment. The prediction model exhibited good discrimination, with an area under the curve (AUC) of 0.82 (95% confidence interval [CI], 0.74-0.90) and good calibration (p = 0.613). The validation analysis showed the AUC of the final prognostic prediction model is 0.80 (95% CI 0.71-0.86) and it has good prediction performance. CONCLUSION The imaging data-based prediction model has demonstrated great prediction accuracy for good hematoma dissolution in mild CSDH patients undergoing atorvastatin treatment. The study results emphasize the importance of imaging data evaluation in the management of CSDH patients.
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Affiliation(s)
- Xinjie Zhang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, 300070, China
- Department of Pediatric Neurosurgery, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zhuang Sha
- Department of Neurosurgery, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, 300070, China
- Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, 300070, China
| | - Dongyi Feng
- Department of Neurosurgery, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, 300070, China
- Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, 300070, China
| | - Chenrui Wu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, 300070, China
- Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, 300070, China
| | - Ye Tian
- Department of Neurosurgery, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, 300070, China
- Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, 300070, China
| | - Dong Wang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, 300070, China
- Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, 300070, China
| | - Junping Wang
- Department of Radiology and Tianjin Key Laboratory of Functional Imaging, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, 300070, China.
| | - Rongcai Jiang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, 300070, China.
- Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Ministry of Education, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, Tianjin, 300070, China.
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Pahwa B, Kazim SF, Vellek J, Alvarez-Crespo DJ, Shah S, Tarawneh O, Dicpinigaitis AJ, Grandhi R, Couldwell WT, Schmidt MH, Bowers CA. Frailty as a predictor of poor outcomes in patients with chronic subdural hematoma (cSDH): A systematic review of literature. World Neurosurg X 2024; 23:100372. [PMID: 38638610 PMCID: PMC11024655 DOI: 10.1016/j.wnsx.2024.100372] [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: 03/04/2023] [Revised: 03/22/2024] [Accepted: 03/22/2024] [Indexed: 04/20/2024] Open
Abstract
Objective In recent years, frailty has been reported to be an important predictive factor associated with worse outcomes in neurosurgical patients. The purpose of the present systematic review was to analyze the impact of frailty on outcomes of chronic subdural hematoma (cSDH) patients. Methods We performed a systematic review of literature using the PubMed, Cochrane library, Wiley online library, and Web of Science databases following PRISMA guidelines of studies evaluating the effect of frailty on outcomes of cSDH published until January 31, 2023. Results A comprehensive literature search of databases yielded a total of 471 studies. Six studies with 4085 patients were included in our final qualitative systematic review. We found that frailty was associated with inferior outcomes (including mortality, complications, recurrence, and discharge disposition) in cSDH patients. Despite varying frailty scales/indices used across studies, negative outcomes occurred more frequently in patients that were frail than those who were not. Conclusions While the small number of available studies, and heterogenous methodology and reporting parameters precluded us from conducting a pooled analysis, the results of the present systematic review identify frailty as a robust predictor of worse outcomes in cSDH patients. Future studies with a larger sample size and consistent frailty scales/indices are warranted to strengthen the available evidence. The results of this work suggest a strong case for using frailty as a pre-operative risk stratification measure in cSDH patients.
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Affiliation(s)
- Bhavya Pahwa
- Medical Student, University College of Medical Sciences and GTB Hospital, New Delhi, India
| | - Syed Faraz Kazim
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), Albuquerque, NM, USA
| | - John Vellek
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | | | - Smit Shah
- Department of Neurology, PRISMA Health/University of South Carolina School of Medicine, Columbia, SC, USA
| | - Omar Tarawneh
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | | | - Ramesh Grandhi
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - William T. Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Meic H. Schmidt
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), Albuquerque, NM, USA
| | - Christian A. Bowers
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), Albuquerque, NM, USA
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Maeda T, Kikkawa Y, Ehara T, Tsuchiya R, Tabata S, Onodera K, Kimura T, Take Y, Suzuki K, Kurita H. Clinical Outcomes in Elderly Patients with Chronic Subdural Hematoma: Validation of Irrigation Assignment Based on Hematoma Characteristics. Life (Basel) 2024; 14:518. [PMID: 38672788 PMCID: PMC11051316 DOI: 10.3390/life14040518] [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: 03/13/2024] [Revised: 04/13/2024] [Accepted: 04/14/2024] [Indexed: 04/28/2024] Open
Abstract
The number of elderly patients with chronic subdural hematomas (CSDH) is increasing worldwide; however, there is limited data regarding the clinical outcomes in this population. Our therapeutic method using burr hole evacuation for CSDH is based on the hematoma characteristics, using simple drainage for single-layer lesions and drainage with irrigation for multiple-layer lesions. This study aimed to compare the postoperative outcomes of elderly and younger patients, identify the predictors of outcomes in elderly patients, and verify the validity of our therapeutic methods. In total, we included 214 patients who underwent burr hole evacuation between April 2018 and March 2022. Baseline characteristics, hematoma characteristics, recurrence, and clinical outcomes were compared between the elderly and younger patients. Overall, 96 elderly patients (44.9%) were included in the study, and more elderly patients underwent antithrombotic therapy than younger patients (33.3% vs. 19.5%, p = 0.027). Moreover, elderly patients had significantly fewer favorable outcomes than younger patients (70.8% vs. 91.5%; p < 0.001); however, this was not significant after adjusting for the baseline modified Rankin Scale (mRS). Similarly, elderly patients had higher recurrence rates than younger patients (10.4% vs. 2.5%; p = 0.021). However, the baseline mRS score was the only predictor of unfavorable outcomes. In conclusion, although the clinical outcomes of elderly patients were comparable to those of younger patients, the higher rate of preoperative antithrombotic therapy in elderly patients may result in a higher rate of recurrence requiring a long-term follow-up.
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Affiliation(s)
- Takuma Maeda
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka 350-1298, Japan
| | - Yuichiro Kikkawa
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka 350-1298, Japan
- Department of Neurosurgery, Saitama Cardiovascular and Respiratory Center, Kumagaya 360-0197, Japan
| | - Takuro Ehara
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka 350-1298, Japan
| | - Ryosuke Tsuchiya
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka 350-1298, Japan
| | - Shinya Tabata
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka 350-1298, Japan
| | - Koki Onodera
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka 350-1298, Japan
| | - Tatsuki Kimura
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka 350-1298, Japan
| | - Yushiro Take
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka 350-1298, Japan
| | - Kaima Suzuki
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka 350-1298, Japan
| | - Hiroki Kurita
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka 350-1298, Japan
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Zhang X, Sha Z, Gao C, Yuan J, He L, Huang J, Jiang R. Factors influencing wait-and-watch management in mild primary chronic subdural hematoma: a retrospective case-control study. Acta Neurol Belg 2023; 123:2277-2286. [PMID: 37269419 DOI: 10.1007/s13760-023-02293-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 05/15/2023] [Indexed: 06/05/2023]
Abstract
PURPOSE To identify prognostic factors in patients with primary chronic subdural hematoma (CSDH) undergoing wait-and-watch management. METHODS A case-control study was conducted in a single center from February 2019 to November 2021 to identify independent influencing factors of wait-and-watch management in mild CSDH patients using wait-and-watch as monotherapy. A total of 39 patients who responded to wait-and-watch management (cases) and 24 nonresponders (controls) matched for age, sex, height, weight, MGS-GCS (Markwalder grading scale and Glasgow Coma Scale), and bilateral hematoma were included. Demographics, blood cell counts, serum biochemical levels, imaging data, and relevant clinical features at baseline were collected. RESULTS Univariate analysis revealed significant differences between cases and controls in hematoma volume, ability to urinate, maximal thickness of the hematoma, and hypodensity of the hematoma. Hypodense hematoma and hematoma volume were independently associated with the outcome in multivariate analysis. Combining these independently influencing factors revealed an area under the receiver operator characteristic curve of 0.741 (95% CI 0.609-0.874, sensitivity = 0.783, specificity = 0.667). CONCLUSIONS The results of this study may aid in identifying patients with mild primary CSDH who could benefit from conservative management. While wait-and-watch management may be an option in some cases, clinicians need to suggest medical interventions, such as pharmacotherapy, when appropriate.
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Affiliation(s)
- Xinjie Zhang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Ministry of Education, Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Tianjin, China
| | - Zhuang Sha
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Ministry of Education, Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Tianjin, China
| | - Chuang Gao
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Ministry of Education, Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Tianjin, China
| | - Jiangyuan Yuan
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Ministry of Education, Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Tianjin, China
| | - Lei He
- Department of Neurology, Chengde Central Hospital, Chengde, 067000, Hebei, China
| | - Jinhao Huang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.
- Ministry of Education, Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Tianjin, China.
| | - Rongcai Jiang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.
- Ministry of Education, Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Tianjin, China.
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Yang W, Chen Q, Yao H, Zhang J, Zhang Q, Fang J, Wu G, Hu J. Predicting the progression of chronic subdural hematoma based on skull density. Front Neurol 2023; 14:1279292. [PMID: 37928152 PMCID: PMC10623350 DOI: 10.3389/fneur.2023.1279292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 10/09/2023] [Indexed: 11/07/2023] Open
Abstract
Objective The objective of this study was to investigate potential correlations between skull density and the progression of chronic subdural hematoma (CSDH). Methods Patients with unilateral CSDH were retrospectively enrolled between January 2018 and December 2022. Demographic and clinical characteristics, as well as hematoma and skull density (Hounsfield unit, Hu), were collected and analyzed. Results The study enrolled 830 patients with unilateral CSDH until the resolution of the CDSH or progressed with surgical treatment. Of the total, 488 patients (58.80%) necessitated surgical treatment. The study identified a significant correlation between the progression of CSDH and three variables: minimum skull density (MiSD), maximum skull density (MaSD), and skull density difference (SDD) (p < 0.001). Additionally, in the multivariable regression analysis, MiSD, MaSD, and SDD were independent predictors of CSDH progression. The MiSD + SDD model exhibited an accuracy of 0.88, as determined by the area under the receiver operating characteristic curve, with a sensitivity of 0.77 and specificity of 0.88. The model's accuracy was validated through additional analysis. Conclusion The findings suggest a significant correlation between skull density and the CSDH progression.
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Affiliation(s)
- Weijian Yang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, China
- Neurosurgical Institute of Fudan University, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Qifang Chen
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, China
- Neurosurgical Institute of Fudan University, Shanghai, China
- Department of Nursing, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Haijun Yao
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, China
- Neurosurgical Institute of Fudan University, Shanghai, China
- Department of Neurosurgery and Neurocritical Care, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Jun Zhang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, China
- Neurosurgical Institute of Fudan University, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Quan Zhang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, China
- Neurosurgical Institute of Fudan University, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Jiang Fang
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, China
- Neurosurgical Institute of Fudan University, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Gang Wu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, China
- Neurosurgical Institute of Fudan University, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
| | - Jin Hu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai, China
- Neurosurgical Institute of Fudan University, Shanghai, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, China
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Morales-Gómez JA, Garcia-Estrada E, Garza-Báez A, Mercado-Flores M, de León AMP. Subdural open drains as an effective and low-cost modality for the treatment of chronic subdural hematomas. Br J Neurosurg 2023; 37:1078-1081. [PMID: 33322934 DOI: 10.1080/02688697.2020.1858024] [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: 03/30/2020] [Accepted: 11/26/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE We present a series that describes the presenting features and clinical outcomes in patients with CSDH treated with a standardised technique and an open-drain placement. METHODS We reviewed the medical records of 155 consecutive patients at a single centre who underwent CSDH evacuation by placing burr holes, accompanied by intraoperative irrigation and a subdural Penrose drain between 2014 and 2018. RESULTS The mean age was 65.9 years, 81.9% were males. The most common clinical characteristics were an altered mental state (21.9%) and headache (12.9%). It was necessary to perform a second surgical intervention due to the evidence in the postoperative tomography of a residual hematoma in 10.3% of the cases; there were 2 cases of recurrence in 6 months (1.3%). Pneumonia (6.5%) and seizures (5.8%) were the most frequent medical complications. Intracranial infections accounted for 1.9%, and the mortality rate was 6.4% of cases. CONCLUSIONS We provided our experience with a low-cost and less-commonly used technique in the management of CSDH. This technique showed similar recurrence, mortality and intracranial infection rates to those reported in the literature for closed drainage systems. Additional studies will be required to assess this technique.
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Affiliation(s)
- Jesús Alberto Morales-Gómez
- Neurosurgery and Neuroendovascular Therapy Department, "Dr. José Eleuterio González" University Hospital, Universidad Autónoma de Nuevo León, Monterrey, México
| | - Everardo Garcia-Estrada
- Neurosurgery and Neuroendovascular Therapy Department, "Dr. José Eleuterio González" University Hospital, Universidad Autónoma de Nuevo León, Monterrey, México
| | - Azalea Garza-Báez
- Neuroradiology Division, University Center for Diagnostic Imaging, "Dr. José Eleuterio González" University Hospital, Universidad Autónoma de Nuevo León, Monterrey, México
| | - Mariana Mercado-Flores
- Neuroradiology Division, University Center for Diagnostic Imaging, "Dr. José Eleuterio González" University Hospital, Universidad Autónoma de Nuevo León, Monterrey, México
| | - Angel Martínez-Ponce de León
- Neurosurgery and Neuroendovascular Therapy Department, "Dr. José Eleuterio González" University Hospital, Universidad Autónoma de Nuevo León, Monterrey, México
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Li Y, Yang X, Zhou H, Hui X, Li H, Zheng J. Comparison of surgical strategies in patients with chronic subdural haematoma: a protocol for a network meta-analysis. BMJ Open 2023; 13:e070595. [PMID: 37597864 PMCID: PMC10441052 DOI: 10.1136/bmjopen-2022-070595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 07/17/2023] [Indexed: 08/21/2023] Open
Abstract
INTRODUCTION Chronic subdural haematoma (CSDH) is one of the most common neurosurgical emergencies, especially in the elderly population. Surgery is the mainstay of treatment for CSDH. Some studies have suggested that some specific surgical strategies can have potential benefits for patients with CSDH; however, the best surgical method is still controversial. For a better understanding of surgical treatment for these patients, it is necessary to conduct a network meta-analysis to comprehensively compare the effects of medical treatment and different surgical methods. METHODS AND ANALYSIS This protocol has been reported following the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols. Related studies published up to April 2023 will be searched in the following databases: PubMed, Embase, Scopus, Web of Science, the Cochrane Library, China National Knowledge Infrastructure, VIP and Wanfang. Randomised controlled trials and non-randomised prospective studies comparing at least two different interventions for patients with CSDH will be included. Quality assessment will be conducted using Cochrane Collaboration's tool or the Newcastle-Ottawa Scale based on study design. The primary outcome will be the recurrence rates, and the secondary outcome will be the functional outcome at the end of follow-up. Pairwise and network meta-analyses will be conducted using STATA V.14 (StataCorp, College Station, Texas, USA). Mean ranks and the surface under the cumulative ranking curve will be used to evaluate each intervention. Statistical inconsistency assessment, subgroup analysis, sensitivity analysis and publication bias assessment will be performed. ETHICS AND DISSEMINATION Ethics approval is not necessary because this study will be based on publications. The results of this study will be published in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42022376829.
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Affiliation(s)
- Yujian Li
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xiang Yang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Huiqing Zhou
- Department of Intensive Care Unit, Fourth People's Hospital of Sichuan Province, Chengdu, Sichuan, China
| | - Xuhui Hui
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Hao Li
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jun Zheng
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, 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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10
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Laeke T, Kalleklev L, Tirsit A, Moen BE, Lund-Johansen M, Sundstrøm T. Surgical treatment and outcome of chronic subdural hematoma: a comparative study between Ethiopia and Norway. Acta Neurochir (Wien) 2023; 165:49-59. [PMID: 36495322 DOI: 10.1007/s00701-022-05435-z] [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: 10/07/2022] [Accepted: 11/14/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Chronic subdural hematoma (CSDH) is one of the most common neurosurgical conditions. Here, we studied differences in demographics, treatment, and outcome for CSDH patients in low-income (Ethiopia) and high-income (Norway) countries and assessed potential outcome determinants. METHODS We included patients from Addis Ababa University Hospitals (AAUH) and Haukeland University Hospital (HUH) who had surgery for CSDH (2013-2017). Patients were included prospectively in Ethiopia and retrospectively in Norway. RESULTS We enrolled 314 patients from AAUH and 284 patients from HUH, with a median age of 60 and 75 years, respectively. Trauma history was more common in AAUH (72%) than in HUH patients (64.1%). More patients at HUH (45.1%) used anticoagulants/antiplatelets than at AAUH (3.2%). Comorbidities were more frequent in HUH (77.5%) than in AAUH patients (30.3%). Burr hole craniostomy under local anesthesia and postoperative drainage was the standard treatment in both countries. Postoperative CT scanning was more common at HUH (99.3%) than at AAUH (5.2%). Reoperations were more frequent at HUH (10.9%) than at AAUH (6.1%), and in both countries, mostly due to hematoma recurrence. Medical complications were more common at HUH (6.7%) than at AAUH (1.3%). The 1-year mortality rate at HUH was 7% and at AAUH 3.5%. At the end of follow-up (> 3 years), the Glasgow Outcome Scale Extended (GOSE) score was 8 in 82.9% of AAUH and 46.8% of HUH patients. CONCLUSION The surgical treatment was similar at AAUH and HUH. The poorer outcome in Norway could largely be explained by age, comorbidity, medication, and complication rates.
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Affiliation(s)
- Tsegazeab Laeke
- Neurosurgery Division, Surgery Department, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Line Kalleklev
- Department of Physical Medicine and Rehabilitation, Haukeland University Hospital, Bergen, Norway
| | - Abenezer Tirsit
- Neurosurgery Division, Surgery Department, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Bente E Moen
- Center for International Health, Department of Global Public Health and Primary Care, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Morten Lund-Johansen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
| | - Terje Sundstrøm
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
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11
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Liu T, Gao Z, Zhou J, Lai X, Chen X, Rao Q, Guo D, Zheng J, Lin F, Lin Y, Lin Z. Subdural evacuating port system with subdural thrombolysis for the treatment of chronic subdural hematoma in patients older than 80 years. Front Neurol 2023; 14:1068829. [PMID: 36873430 PMCID: PMC9975157 DOI: 10.3389/fneur.2023.1068829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 01/17/2023] [Indexed: 02/17/2023] Open
Abstract
Objective The subdural evacuating port system (SEPS) is a minimally invasive approach that can be performed under local anesthesia for the treatment of chronic subdural hematoma (CSDH). Subdural thrombolysis has been described as an exhaustive drainage strategy and found to be safe and effective for improving drainage. We aim to analyze the effectiveness of SEPS with subdural thrombolysis in patients older than 80 years. Method Consecutive patients aged ≥80 years old who presented with symptomatic CSDH and underwent SEPS followed by subdural thrombolysis between January 2014 and February 2021 were retrospectively studied. Outcome measures included complications, mortality, recurrence, and modified Rankin Scale (mRS) scores at discharge and 3 months. Results In total, 52 patients with CSDH in 57 hemispheres were operated on, with a mean age of 83.9 ± 3.3 years, and 40 (76.9%) patients were men. The preexisting medical comorbidities were observed in 39 patients (75.0%). Postoperative complications occurred in nine patients (17.3%), with two having significant complications (3.8%). The complications observed included pneumonia (11.5%), acute epidural hematoma (3.8%), and ischemic stroke (3.8%). One patient experienced contralateral malignant middle cerebral artery infarction and died of subsequent severe herniation, contributing to a perioperative mortality rate of 1.9%. Discharge and 3 months of favorable outcomes (mRS score 0-3) were achieved in 86.5% and 92.3% of patients, respectively. CSDH recurrence was observed in five patients (9.6%), and repeat SEPS was performed. Conclusion As an exhaustive drainage strategy, SEPS followed by thrombolysis is safe and effective with excellent outcomes among elderly patients. It is a technically easy and less invasive procedure with similar complications, mortality, and recurrence rates compared with burr-hole drainage in the literature.
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Affiliation(s)
- Tianqing Liu
- Department of Neurosurgery, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, Fujian, China
| | - Zhenwen Gao
- Department of Neurosurgery, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, Fujian, China
| | - Jianjun Zhou
- Department of Neurosurgery, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, Fujian, China
| | - Xiaoyan Lai
- Department of Neurosurgery, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, Fujian, China
| | - Xiaomei Chen
- Department of Neurosurgery, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, Fujian, China
| | - Qiong Rao
- Department of Neurosurgery, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, Fujian, China
| | - Dongbin Guo
- Department of Neurosurgery, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, Fujian, China
| | - Jinliang Zheng
- Department of Neurosurgery, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, Fujian, China
| | - Fuxin Lin
- Department of Neurosurgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Yuanxiang Lin
- Department of Neurosurgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Zhiqin Lin
- Department of Neurosurgery, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, Fujian, China.,Department of Neurosurgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
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12
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Keong NC, Lock C, Soon S, Hernowo AT, Czosnyka Z, Czosnyka M, Pickard JD, Narayanan V. Diffusion Tensor Imaging Profiles Can Distinguish Diffusivity and Neural Properties of White Matter Injury in Hydrocephalus vs. Non-hydrocephalus Using a Strategy of a Periodic Table of DTI Elements. Front Neurol 2022; 13:868026. [PMID: 35873785 PMCID: PMC9296826 DOI: 10.3389/fneur.2022.868026] [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: 02/02/2022] [Accepted: 04/01/2022] [Indexed: 11/13/2022] Open
Abstract
Background:The aim of this study was to create a simplistic taxonomy to improve transparency and consistency in, and reduce complexity of, interpreting diffusion tensor imaging (DTI) profiles in white matter disruption. Using a novel strategy of a periodic table of DTI elements, we examined if DTI profiles could demonstrate neural properties of disruption sufficient to characterize white matter changes specific for hydrocephalus vs. non-hydrocephalus, and to distinguish between cohorts of neural injury by their differing potential for reversibility.MethodsDTI datasets from three clinical cohorts representing pathological milestones from reversible to irreversible brain injury were compared to those of healthy controls at baseline, over time and with interventions. The final dataset comprised patients vs. controls in the following groupings: mild traumatic brain injury (mTBI), n = 24 vs. 27, normal pressure hydrocephalus (NPH), n = 16 vs. 9 and Alzheimer's disease (AD), n = 27 vs. 47. We generated DTI profiles from fractional anisotropy (FA) and mean, axial and radial diffusivity measures (MD, L1 and L2 and 3 respectively), and constructed an algorithm to map changes consistently to a periodic table of elements, which fully described their diffusivity and neural properties.ResultsMapping tissue signatures to a periodic table of DTI elements rapidly characterized cohorts by their differing patterns of injury. At baseline, patients with mTBI displayed the most preserved tracts. In NPH, the magnitude of changes was dependent on “familial” DTI neuroanatomy, i.e., potential for neural distortion from risk of ventriculomegaly. With time, patients with Alzheimer's disease were significantly different to controls across multiple measures. By contrast, patients with mTBI showed both loss of integrity and pathophysiological processes of neural repair. In NPH, some patterns of injury, such as “stretch/compression” and “compression” were more reversible following intervention than others; these neural profile properties suggested “microstructural resilience” to injury.ConclusionUsing the novel strategy of a periodic table of DTI elements, our study has demonstrated it is possible to distinguish between different cohorts along the spectrum of brain injury by describing neural profile properties of white matter disruption. Further work to contribute datasets of disease toward this proposed taxonomic framework would enhance the translatability of DTI profiles to the clinical-research interface.
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Affiliation(s)
- Nicole C. Keong
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
- *Correspondence: Nicole C. Keong
| | - Christine Lock
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore
| | - Shereen Soon
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore
| | - Aditya Tri Hernowo
- Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Zofia Czosnyka
- Neurosurgical Division, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Marek Czosnyka
- Neurosurgical Division, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - John D. Pickard
- Neurosurgical Division, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Vairavan Narayanan
- Department of Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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13
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Shlobin NA, Kedda J, Wishart D, Garcia RM, Rosseau G. Surgical Management of Chronic Subdural Hematoma in Older Adults: A Systematic Review. J Gerontol A Biol Sci Med Sci 2021; 76:1454-1462. [PMID: 33220683 DOI: 10.1093/gerona/glaa293] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Chronic subdural hematoma (cSDH) is a form of intracranial hemorrhage common in older adults. Optimal treatment remains controversial. We conducted a systematic review to identify surgical thresholds, characterize outcomes, and delineate critical considerations in the surgical management of older adults in order to summarize the evidence supporting the best contemporary management of cSDH. METHODS A systematic review exploring surgical management of cSDH among individuals aged 65 years and older was conducting by searching the PubMed, Embase, and Scopus databases for articles in English. Abstracts from articles were read and selected for full-text review according to a priori criteria. Relevant full-text articles were analyzed for bibliographic data, aim, study design, population, interventions, and outcomes. RESULTS Of 1473 resultant articles, 21 were included. Surgery rationale was case-by-case for symptomatic patients with cSDH. Surgery was superior to conservative management and promoted equivalent neurologic outcomes and rates of complications. Recurrence and reoperation rates in older adults were similar to younger individuals. Some studies reported higher mortality rates for older adults, while others reported no difference. Anticoagulation or antiplatelet agent use did not seem to be associated with poorer outcomes in older adults. CONCLUSIONS Surgery for cSDH in older adults leads to favorable neurologic outcomes without increased risk of overall complications, recurrence, or reoperation compared to younger patients. However, older adults may be at increased risk for mortality after surgery. It is important to determine use of anticoagulant or antiplatelet agents in older adults to optimally manage patients with cSDH.
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Affiliation(s)
- Nathan A Shlobin
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jayanidhi Kedda
- Department of Neurosurgery, George Washington University School of Medicine & Health Sciences, Washington, District of Columbia
| | - Danielle Wishart
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Roxanna M Garcia
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Gail Rosseau
- Department of Neurosurgery, George Washington University School of Medicine & Health Sciences, Washington, District of Columbia
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14
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Zhang X, Wang D, Tian Y, Wei H, Liu X, Xiang T, Fan Y, Gao C, Huang J, Sha Z, Quan W, Zhang J, Jiang R. Risk Factors for Atorvastatin as a Monotherapy for Chronic Subdural Hematoma: A Retrospective Multifactor Analysis. Front Aging Neurosci 2021; 13:726592. [PMID: 34539386 PMCID: PMC8440973 DOI: 10.3389/fnagi.2021.726592] [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: 06/17/2021] [Accepted: 08/09/2021] [Indexed: 11/23/2022] Open
Abstract
Chronic subdural hematoma (CSDH) is a common form of intracranial hemorrhage in the aging population. We aimed to investigate the predictive factors for atorvastatin efficacy as a monotherapy for moderate CSDH. We retrospectively reviewed the medical records of patients who were diagnosed with moderate CSDH and received atorvastatin monotherapy between February 5, 2014, and November 7, 2015, in multiple neurosurgical departments. Univariate, multivariate and receiver operating characteristic curve analyses were performed to identify the potential significant factors indicative of the good therapeutic efficacy or poor therapeutic efficacy of atorvastatin for mild CSDH, such as age, sex, history of injury, Markwalder grading scale–Glasgow Coma Scale (MGS-GCS), Activities of Daily Life-the Barthel Index scale (ADL-BI), American Society of Anesthesiologists Physical Status classification system (ASA-PS), blood cell counts, serum levels and computed tomography findings. A total of 89 patients (75 men and 14 women) aged 24–88 years (mean age 61.95 ± 15.30 years) were followed-up for 24 weeks. Computed tomography findings at admission showed mixed-density hematoma in 22 patients, isodense hematoma in 13 patients, high-density hematoma in 26 patients, and low-density hematoma in 28 patients. In total, 3, 80, and 6 patients had MGS-GCS grades of 0, 1, and 2, respectively. The efficacy rate at 6 months was 87.6% (78/89). Eleven patients were switched to surgery due to a worsened neurological condition, of whom 8, 1, 1, and 1 had high-density, low-density, isodense and mixed-density hematomas, respectively. These patients were switched to surgery over a range of 2–27 days, with a median interval of 12 days after the medication treatment. Univariate and multivariate analyses, confirmed by ROC curves, revealed that high-density hematoma, basal cistern compression, and hematoma volume to be independent risk factors for the efficacy of atorvastatin monotherapy in patients with moderate CSDH. Atorvastatin is an effective monotherapy for the treatment of mild CSDH. High-density hematoma, basal cistern compression, and hematoma volume are independent predictors of the efficacy of atorvastatin as a non-surgical treatment. The results suggested that ADL-BI was more sensitive than the MGS-GCS and ASA-PS for determining patient outcomes in our moderate CSDH cohort.
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Affiliation(s)
- Xinjie Zhang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Dong Wang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Ye Tian
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Huijie Wei
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Xuanhui Liu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Tangtang Xiang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Yibing Fan
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Chuang Gao
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Jinhao Huang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Zhuang Sha
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Wei Quan
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Jianning Zhang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Rongcai Jiang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
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15
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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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16
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Ironside N, Nguyen C, Do Q, Ugiliweneza B, Chen CJ, Sieg EP, James RF, Ding D. Middle meningeal artery embolization for chronic subdural hematoma: a systematic review and meta-analysis. J Neurointerv Surg 2021; 13:951-957. [PMID: 34193592 DOI: 10.1136/neurintsurg-2021-017352] [Citation(s) in RCA: 76] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 06/13/2021] [Indexed: 12/13/2022]
Abstract
Middle meningeal artery (MMA) embolization has been proposed as a minimally invasive treatment for chronic subdural hematoma (cSDH). The aim of this systematic review and meta-analysis is to compare outcomes after MMA embolization versus conventional management for cSDH. We performed a systematic review of PubMed, Embase, Oxford Journal, Cochrane, and Google Scholar databases from April 1987 to October 2020 in accordance with PRISMA guidelines. Studies reporting outcomes after MMA embolization for ≥3 patients with cSDH were included. A meta-analysis comparing MMA embolization with conventional management was performed. The analysis comprised 20 studies with 1416 patients, including 718 and 698 patients in the MMA embolization and conventional management cohorts, respectively. The pooled recurrence, surgical rescue, and in-hospital complication rates in the MMA embolization cohort were 4.8% (95% CI 3.2% to 6.5%), 4.4% (2.8% to 5.9%), and 1.7% (0.8% to 2.6%), respectively. The pooled recurrence, surgical rescue, and in-hospital complication rates in the conventional management cohort were 21.5% (0.6% to 42.4%), 16.4% (5.9% to 27.0%), and 4.9% (2.8% to 7.1%), respectively. Compared with conservative management, MMA embolization was associated with lower rates of cSDH recurrence (OR=0.15 (95% CI 0.03 to 0.75), p=0.02) and surgical rescue (OR=0.21 (0.07 to 0.58), p=0.003). In-hospital complication rates were comparable between the two cohorts (OR=0.78 (0.34 to 1.76), p=0.55). MMA embolization is a promising minimally invasive therapy that may reduce the need for surgical intervention in appropriately selected patients with cSDH. Additional prospective studies are warranted to determine the long-term durability of MMA embolization, refine eligibility criteria, and establish this endovascular approach as a viable definitive treatment for cSDH.
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Affiliation(s)
- Natasha Ironside
- Department of Neurosurgery, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Candice Nguyen
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Quan Do
- Department of Internal Medicine, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Beatrice Ugiliweneza
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Ching-Jen Chen
- Department of Neurosurgery, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Emily P Sieg
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Robert F James
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Dale Ding
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky, USA
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Role of prophylactic antiepileptic drugs in chronic subdural hematoma-a systematic review and meta-analysis. Neurosurg Rev 2020; 44:2069-2077. [PMID: 32910368 DOI: 10.1007/s10143-020-01388-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 08/30/2020] [Accepted: 09/03/2020] [Indexed: 10/23/2022]
Abstract
Chronic subdural hematoma is a common neurosurgical pathology, which is more commonly seen in the elderly age group. Few patients with chronic subdural hematoma (cSDH) can have seizures-either before or after surgical intervention. Reported incidence of seizures varies from 0.7-18.5% in patients with cSDH. Many factors which have been proposed to increase the risk of seizures in these patients include the presence of encapsulated membranes, occult cortical injury, mass effect, or an acute hemorrhage. The role of prophylactic antiepileptic drugs is not very clear in cSDH. We reviewed the currently available evidence for the use of prophylactic antiepileptic drugs (AEDs) in patients with cSDH. We included 13 studies in the systematic review and 6 studies compared the incidence of seizures in patients who received antiepileptic drugs with those who did not. Our review did not find any significant reduction in the incidence of seizures in patients with cSDH following administration of antiepileptic drugs.
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McIntyre MK, Rawanduzy C, Afridi A, Honig JA, Halabi M, Hehir J, Schmidt M, Cole C, Miller I, Gandhi C, Al-Mufti F, Bowers CA. The Effect of Frailty versus Initial Glasgow Coma Score in Predicting Outcomes Following Chronic Subdural Hemorrhage: A Preliminary Analysis. Cureus 2020; 12:e10048. [PMID: 32983738 PMCID: PMC7515811 DOI: 10.7759/cureus.10048] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background Initial Glasgow Coma Score (iGCS) is a well-known predictor of adverse outcomes following chronic subdural hemorrhage (cSDH). Frailty, i.e. a reduced physiologic reserve, is associated with poorer outcomes across the surgical literature, however, there is no consensus on the best measure of frailty. To date, no study has compared frailty’s ability to predict cSDH outcomes versus iGCS. The goal of this study was to, therefore, examine the prognostic value of the 5- (mFI-5) and 11-factor (mFI-11) modified frailty index, and Charlson Comorbidity Index (CCI) versus iGCS following cSDH. Methods Between January, 2016 and June, 2018, patients who presented to the emergency department with cSDH were retrospectively identified using the International Classification of Diseases (ICD) codes. mFI-5, mFI-11, and CCI scores were calculated using patient baseline characteristics. Primary endpoints were death and discharge home and subgroup analyses were performed among operative cSDH. Univariate and multivariate logistic regressions were used to determine predictors of primary endpoints. Results Of the 109 patients identified, the average age was 72.6±1.6 years and the majority (69/109, 63.3%) were male. The average CCI, mFI-5, and mFI-11 were 4.5 ±0.2, 1.5 ±0.1, and 2.2 ±0.1, respectively. Fifty (45.9%) patients required surgical intervention, 11 (10.1%) died, and 48 (43.4%) were discharged home. In the overall cohort, while the only multivariate predictor of mortality was iGCS (OR=0.58; 95%CI:0.44-0.77; p=0.0001), the CCI (OR=0.73; 95%CI:0.58-0.92; p=0.0082) was a superior predictor of discharge home compared to iGCS (OR=1.46; 95%CI:1.13-1.90; p=0.0041). Conversely, among those who received an operative intervention, the CCI, but not iGCS, independently predicted both mortality (OR=4.24; 95%CI:1.01-17.86; p=0.0491) and discharge home (OR=0.55; 95%CI:0.33-0.90; p=0.0170). Neither mFI nor age predicted primary outcomes in multivariate analysis. Conclusion While frailty is associated with worse surgical outcomes, the clinical utility of the mFI-5, mFI-11, and CCI in cSDH is unclear. We show that the iGCS is an overall superior predictor of mortality following cSDH but is outperformed by the CCI after operative intervention. Similarly, the CCI is the superior predictor of discharge home in cSDH patients overall and following an operative intervention. These results indicate that while the iGCS best predicts mortality overall, the CCI may be considered when prognosticating post-operative course and hospital disposition.
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Affiliation(s)
- Matthew K McIntyre
- Department of Neurological Surgery, Oregon Health & Science University, Portland, USA.,Department of Neurosurgery, New York Medical College, Valhalla, USA
| | | | - Adil Afridi
- Department of Neurosurgery, New York Medical College, Valhalla, USA
| | - Jesse A Honig
- Department of Neurosurgery, New York Medical College, Valhalla, USA
| | - Mohamed Halabi
- Department of Neurosurgery, New York Medical College, Valhalla, USA
| | - Jake Hehir
- Department of Neurosurgery, New York Medical College, Valhalla, USA
| | - Meic Schmidt
- Department of Neurosurgery, University of New Mexico, Albuquerque, USA
| | - Chad Cole
- Department of Neurosurgery, Westchester Medical Center, Valhalla, USA
| | - Ivan Miller
- Department of Emergency Medicine, Westchester Medical Center, Valhalla, USA
| | - Chirag Gandhi
- Department of Neurosurgery, Westchester Medical Center, Valhalla, USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center, Valhalla, USA
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Tong Y, Liu W, Xu L, Ou Y, Li K, Yang T, Zhao T, Guan R, Fan Y. Nonsurgical treatment of chronic subdural hematoma with Chinese herbal medicine: A STROBE-compliant retrospective study. Medicine (Baltimore) 2020; 99:e21674. [PMID: 32872034 PMCID: PMC7437851 DOI: 10.1097/md.0000000000021674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The aim of the study was to observe the efficacy of nonsurgical treatment with Chinese herbal medicine (CHM) for chronic subdural hematoma (CSDH). This study includes clinical results of a STROBE-compliant retrospective study.Forty patients diagnosed with CSDH were recruited from outpatient. Different CHM prescriptions were dispensed for each patient based on syndrome differentiation until the patient had a stable neurologic condition for 2 weeks and/or CSDH completely resolved according to the computed tomography scan. Markwalder grading scale for neurologic symptoms and head computed tomography scan for hematoma volumes were performed before and after CHM treatment to evaluate efficacy.Patients received uninterrupted CHM treatment for 2.81 ± 1.45 months (0.75-6 months). The hematoma volume significantly reduced from 73.49 ± 35.43 mL to 14.72 ± 15.94 mL (P < .001). The Markwalder grading scale scores of patients at the end of CHM treatment decreased significantly, from 1.3 ± 0.69 to 0.15 ± 0.36 (P < .001). Ninety percent of the patients showed >50% decrease in the hematoma volume and complete improvement in neurologic symptoms. The linear regression analysis suggested that change in hematoma was significantly related to the duration of CHM treatment (R = 0.334; P < .001; Ŷ = 25.03 + 11.91X). Leonurus heterophyllus Sweet (Yi-Mu-Cao, 90.5%), Semen persicae (Tao-Ren, 88.8%), and Acorus tatarinowii Schott (Shi-Chang-Pu, 86.2%) were the top 3 single Chinese herbs prescribed in CHM treatment.The CHM treatment for CSDH based on syndrome differentiation with appropriate duration relieved neurologic symptoms quickly and promoted hematoma absorption effectively. It could be an effective nonsurgical therapy for CSDH.
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Affiliation(s)
- Yanping Tong
- Department of Traditional Chinese Medicine Beijing Tiantan Hospital, Capital Medical University
- Beijing Integrative Medicine on Encephalopathy Research Institution, Beijing Tiantan Hospital Capital Medical University
| | - Weiming Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Long Xu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yunwei Ou
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Kangning Li
- Department of Traditional Chinese Medicine Beijing Tiantan Hospital, Capital Medical University
- Beijing Integrative Medicine on Encephalopathy Research Institution, Beijing Tiantan Hospital Capital Medical University
| | - Tao Yang
- Department of Traditional Chinese Medicine Beijing Tiantan Hospital, Capital Medical University
- Beijing Integrative Medicine on Encephalopathy Research Institution, Beijing Tiantan Hospital Capital Medical University
| | - Tianyou Zhao
- Department of Traditional Chinese Medicine Beijing Tiantan Hospital, Capital Medical University
- Beijing Integrative Medicine on Encephalopathy Research Institution, Beijing Tiantan Hospital Capital Medical University
| | - Ruixi Guan
- Department of Traditional Chinese Medicine Beijing Tiantan Hospital, Capital Medical University
- Beijing Integrative Medicine on Encephalopathy Research Institution, Beijing Tiantan Hospital Capital Medical University
| | - Yongping Fan
- Department of Traditional Chinese Medicine Beijing Tiantan Hospital, Capital Medical University
- Beijing Integrative Medicine on Encephalopathy Research Institution, Beijing Tiantan Hospital Capital Medical University
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20
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The immense heterogeneity of frailty in neurosurgery: a systematic literature review. Neurosurg Rev 2020; 44:189-201. [PMID: 31953785 DOI: 10.1007/s10143-020-01241-2] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 01/07/2020] [Accepted: 01/08/2020] [Indexed: 12/21/2022]
Abstract
The aim of this study was to review and analyze the neurosurgery body of literature to document the current knowledge of frailty within neurosurgery, standardizing terminology and how frailty is defined, including the different levels of frailty, while determining what conclusions can be drawn about frailty's impact on neurosurgical outcomes. While multiple studies on frailty in neurosurgery exist, no literature reviews have been conducted. Therefore, we performed a literature review in order to organize, tabulate, and present findings from the data to broaden the understanding about what we know from frailty and neurosurgery. We performed a PubMed search to identify studies that evaluated frailty and neurosurgery. The terms "frail," "frailty," "neurosurgery," "spine surgery," "craniotomy," and "neurological surgery" were all used in the query. We then organized, analyzed, and summarized the comprehensive frailty and neurosurgical literature. The literature contained 25 published studies analyzing frailty in neurosurgery between December 2015 and December 2018. Five of these studies were cranial neurosurgical studies, the remaining studies focused on spinal neurosurgery. Over 100,000 surgical cases were analyzed among the 25 studies. Of these, 18 studies demonstrated that increasing frailty was associated with increased rate of complications, 10 studies showed that frailty was associated with higher mortality rates, 11 studies demonstrated an association between frailty and increased hospital length of stay, and 5 studies noted that higher frailty was associated with discharge to a higher level of care. The current body of literature repeatedly demonstrates that frailty is associated with worse outcomes across the neurosurgical subspecialties.
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21
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Jiang R, Zhao S, Wang R, Feng H, Zhang J, Li X, Mao Y, Yuan X, Fei Z, Zhao Y, Yu X, Poon WS, Zhu X, Liu N, Kang D, Sun T, Jiao B, Liu X, Yu R, Zhang J, Gao G, Hao J, Su N, Yin G, Zhu X, Lu Y, Wei J, Hu J, Hu R, Li J, Wang D, Wei H, Tian Y, Lei P, Dong JF, Zhang J. Safety and Efficacy of Atorvastatin for Chronic Subdural Hematoma in Chinese Patients: A Randomized ClinicalTrial. JAMA Neurol 2019; 75:1338-1346. [PMID: 30073290 DOI: 10.1001/jamaneurol.2018.2030] [Citation(s) in RCA: 151] [Impact Index Per Article: 30.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Chronic subdural hematoma (CSDH) is a trauma-associated condition commonly found in elderly patients. Surgery is currently the treatment of choice, but it carries a significant risk of recurrence and death. Nonsurgical treatments remain limited and ineffective. Our recent studies suggest that atorvastatin reduces hematomas and improves the clinical outcomes of patients with CSDH. Objective To investigate the safety and therapeutic efficacy of atorvastatin to nonsurgically treat patients with CSDH. Design, Setting, and Participants The Effect of Atorvastatin on Chronic Subdural Hematoma (ATOCH) randomized, placebo-controlled, double-blind phase II clinical trial was conducted in multiple centers in China from February 2014 to November 2015. For this trial, we approached 254 patients with CSDH who received a diagnosis via a computed tomography scan; of these, 200 (78.7%) were enrolled because 23 patients (9.1%) refused to participate and 31 (12.2%) were disqualified. Interventions Patients were randomly assigned to receive either 20 mg of atorvastatin or placebo daily for 8 weeks and were followed up for an additional 16 weeks. Main Outcomes and Measures The primary outcome was change in hematoma volume (HV) by computed tomography after 8 weeks of treatment. The secondary outcomes included HV measured at the 4th, 12th, and 24th weeks and neurological function that was evaluated using the Markwalder grading scale/Glasgow Coma Scale and the Barthel Index at the 8th week. Results One hundred ninety-six patients received treatment (169 men [86.2%]; median [SD] age, 63.6 [14.2] years). The baseline HV and clinical presentations were similar between patients who were taking atorvastatin (98 [50%]) and the placebo (98 [50%]). After 8 weeks, the HV reduction in patients who were taking atorvastatin was 12.55 mL more than those taking the placebo (95% CI, 0.9-23.9 mL; P = .003). Forty-five patients (45.9%) who were taking atorvastatin significantly improved their neurological function, but only 28 (28.6%) who were taking the placebo did, resulting in an adjusted odds ratio of 1.957 for clinical improvements (95% CI, 1.07-3.58; P = .03). Eleven patients (11.2%) who were taking atorvastatin and 23 (23.5%) who were taking the placebo underwent surgery during the trial for an enlarging hematoma and/or a deteriorating clinical condition (hazard ratio, 0.47; 95% CI, 0.24-0.92; P = .03). No significant adverse events were reported. Conclusions and Relevance Atorvastatin may be a safe and efficacious nonsurgical alternative for treating patients with CSDH. Trial Registration ClinicalTrials.gov Identifier: NCT02024373.
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Affiliation(s)
- Rongcai Jiang
- Key Laboratory of Post-Neurotrauma Neurorepair and Regeneration in Central Nervous System, Ministry of Education in China and Tianjin, Tianjin Neurological Institute, Tianjin, China
| | - Shiguang Zhao
- Department of Neurosurgery, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Renzhi Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Beijing, China
| | - Hua Feng
- Department of Neurosurgery, Southwest Hospital, Chongqing, China
| | - Jianmin Zhang
- Department of Neurosurgery, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xingang Li
- Department of Neurosurgery, Qilu Hospital of Shandong University, Jinan, China
| | - Ying Mao
- Department of Neurosurgery, Huashan Hospital Fudan University, Shanghai, China
| | - Xianrui Yuan
- Department of Neurosurgery, Xiangya Hospital of Central South University, Changsha, China
| | - Zhou Fei
- Department of Neurosurgery, Xijing Hospital, Xian, China
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing TianTan Hospital, the Capital Medical University, Beijing, China
| | - Xinguang Yu
- Department of Neurosurgery, General Hospital of Chinese People's Liberation Army, Beijing, China
| | - Wai Sang Poon
- Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Shatin, Hong Kong
| | - Xide Zhu
- Department of Neurosurgery, Linyi People's Hospital, Linyi, China
| | - Ning Liu
- Department of Neurosurgery, Jiangsu Provincial Hospital, Nanjing Medical University First Affiliated Hospital, Nanjing, China
| | - Dezhi Kang
- Department of Neurosurgery, First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Tao Sun
- Department of Neurosurgery, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Baohua Jiao
- Department of Neurosurgery, Second Affiliated Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xianzhi Liu
- Department of Neurosurgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Rutong Yu
- Department of Neurosurgery, Affiliated Hospital of Xuzhou Medical College, Xuzhou, China
| | - Junyi Zhang
- Department of Neurosurgery, Central Hospital of Erdos, Erdos, China
| | - Guodong Gao
- Department of Neurosurgery, Xi'an Tangdu Hospital of the fourth Military Medical University, Xian, China
| | - Jiehe Hao
- Department of Neurosurgery, First Affiliated Hospital of Shanxi Medical University, Taiyuan, China
| | - Ning Su
- Department of Neurosurgery, Provincial People's Hospital of Inner Mongolia, Huhehot, China
| | - Gangfeng Yin
- Department of Neurosurgery, Cangzhou Central Hospital, Cangzhou, China
| | - Xingen Zhu
- Department of Neurosurgery, Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yicheng Lu
- Department of Neurosurgery, Shanghai Changzheng Hospital, Shanghai, China
| | - Junji Wei
- Department of Neurosurgery, Peking Union Medical College Hospital, Beijing, China
| | - Jin Hu
- Department of Neurosurgery, Huashan Hospital Fudan University, Shanghai, China
| | - Rong Hu
- Department of Neurosurgery, Southwest Hospital, Chongqing, China
| | - Jianrong Li
- Department of Neurosurgery, 117th Hospital of Chinese People's Liberation Army, Hangzhou, China
| | - Dong Wang
- Key Laboratory of Post-Neurotrauma Neurorepair and Regeneration in Central Nervous System, Ministry of Education in China and Tianjin, Tianjin Neurological Institute, Tianjin, China
| | - Huijie Wei
- Key Laboratory of Post-Neurotrauma Neurorepair and Regeneration in Central Nervous System, Ministry of Education in China and Tianjin, Tianjin Neurological Institute, Tianjin, China
| | - Ye Tian
- Key Laboratory of Post-Neurotrauma Neurorepair and Regeneration in Central Nervous System, Ministry of Education in China and Tianjin, Tianjin Neurological Institute, Tianjin, China
| | - Ping Lei
- Laboratory of Neuro-Trauma and Neurodegenerative Disorders, Tianjin Geriatrics Institute, Tianjin Medical University General Hospital, Tianjin, China.,Department of Geriatrics, Tianjin Medical University General Hospital, Tianjin, China
| | - Jing-Fei Dong
- Bloodworks Research Institute, Division of Hematology, Department of Medicine, University of Washington School of Medicine, Seattle
| | - Jianning Zhang
- Key Laboratory of Post-Neurotrauma Neurorepair and Regeneration in Central Nervous System, Ministry of Education in China and Tianjin, Tianjin Neurological Institute, Tianjin, China
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Standardized assessment of outcome and complications in chronic subdural hematoma: results from a large case series. Acta Neurochir (Wien) 2019; 161:1297-1304. [PMID: 31106394 DOI: 10.1007/s00701-019-03884-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2018] [Accepted: 03/20/2019] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Chronic subdural hematomas (cSDH) are commonly deemed to have a benign prognosis. However, detailed and standardized data describing outcome and complications in a large prospective patient cohort is lacking. METHODS Retrospective analysis of prospectively collected data in our institutional patient registry on consecutive patients undergoing surgery for cSDH from 2013 to 2017. Complications were assessed according to the Clavien-Dindo grading system (CDG). The outcome was measured with respect to two endpoints: occurrence of a complication with CDG 3-5 and lack of improvement in Karnofsky Performance Status (KPS) at the last follow-up. RESULTS Out of 435 operations, 166 (38.3%) presented a complication until 3 months postoperative (CDG 1, 23 (5.3%); CDG 2, 62 (14.3%); CDG 3a, 7 (1.6%); CDG 3b, 64 (14.7%); CDG 4a, 2 (0.5%); and CDG 5, 8 (1.8%)). Higher CDG correlated with a lower KPS (rs = - 0.27, p < 0.001). A lack of improvement in KPS was associated with a Charlson Comorbidity Index (CCI) > 1 and the iso- or hypodense appearance of the cSDH. CONCLUSIONS This study provides a reliable estimate of the rate of medical and surgical complications in cSDH surgery. Complications that required a surgical intervention turned out to be rare. Recording complications in a standardized and prospective fashion can therefore serve as a basis for assessing patient outcome and quality control within the department.
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Maldaner N, Sosnova M, Sarnthein J, Bozinov O, Regli L, Stienen MN. Predicting Functional Impairment in patients with chronic subdural hematoma treated with burr hole Trepanation—The FIT-score. Clin Neurol Neurosurg 2019; 182:142-147. [DOI: 10.1016/j.clineuro.2019.05.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 05/06/2019] [Accepted: 05/13/2019] [Indexed: 10/26/2022]
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Chronic subdural hematoma in patients aged 80 years and older: A two-centre study. Clin Neurol Neurosurg 2018; 170:88-92. [DOI: 10.1016/j.clineuro.2018.05.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Revised: 04/06/2018] [Accepted: 05/02/2018] [Indexed: 11/23/2022]
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Bartek J, Sjåvik K, Schaible S, Gulati S, Solheim O, Förander P, Jakola AS. The Role of Angiotensin-Converting Enzyme Inhibitors in Patients with Chronic Subdural Hematoma: A Scandinavian Population-Based Multicenter Study. World Neurosurg 2018; 113:e555-e560. [DOI: 10.1016/j.wneu.2018.02.094] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 02/14/2018] [Accepted: 02/15/2018] [Indexed: 10/18/2022]
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Christopher E, Poon MTC, Glancz LJ, Hutchinson PJ, Kolias AG, Brennan PM. Outcomes following surgery in subgroups of comatose and very elderly patients with chronic subdural hematoma. Neurosurg Rev 2018; 42:427-431. [PMID: 29679178 PMCID: PMC6502770 DOI: 10.1007/s10143-018-0979-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Revised: 03/28/2018] [Accepted: 04/09/2018] [Indexed: 11/15/2022]
Abstract
Increasing age and lower pre-operative Glasgow coma score (GCS) are associated with worse outcome after surgery for chronic subdural haematoma (CSDH). Only few studies have quantified outcomes specific to the very elderly or comatose patients. We aim to examine surgical outcomes in these patient groups. We analysed data from a prospective multicentre cohort study, assessing the risk of recurrence, death, and unfavourable functional outcome of very elderly (≥ 90 years) patients and comatose (pre-operative GCS ≤ 8) patients following surgical treatment of CSDH. Seven hundred eighty-five patients were included in the study. Thirty-two (4.1%) patients had pre-operative GCS ≤ 8 and 70 (8.9%) patients were aged ≥ 90 years. A higher proportion of comatose patients had an unfavourable functional outcome (38.7 vs 21.7%; p = 0.03), although similar proportion of comatose (64.5%) and non-comatose patients (61.8%) functionally improved after surgery (p = 0.96). Compared to patients aged < 90 years, a higher proportion of patients aged ≥ 90 years had unfavourable functional outcome (41.2 vs 20.5%; p < 0.01), although approximately half had functional improvement following surgery. Mortality risk was higher in both comatose (6.3 vs 1.9%; p = 0.05) and very elderly (8.8 vs 1.1%; p < 0.01) groups. There was a trend towards a higher recurrence risk in the comatose group (19.4 vs 9.5%; p = 0.07). Surgery can still provide considerable benefit to very elderly and comatose patients despite their higher risk of morbidity and mortality. Further research would be needed to better identify those most likely to benefit from surgery in these groups.
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Affiliation(s)
- Edward Christopher
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Michael T C Poon
- Translational Neurosurgery, Centre for Clinical Brain Sciences, University of Edinburgh and Western General Hospital, Edinburgh, UK
| | | | - Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, UK.,Surgery Theme, Cambridge Clinical Trials Unit, Cambridge Biomedical Campus, Cambridge, UK
| | - Angelos G Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, UK.,Surgery Theme, Cambridge Clinical Trials Unit, Cambridge Biomedical Campus, Cambridge, UK
| | - Paul M Brennan
- Translational Neurosurgery, Centre for Clinical Brain Sciences, University of Edinburgh and Western General Hospital, Edinburgh, UK. .,Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK.
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27
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Franko LR, Sheehan KM, Roark CD, Joseph JR, Burke JF, Rajajee V, Williamson CA. A propensity score analysis of the impact of surgical intervention on unexpected 30-day readmission following admission for subdural hematoma. J Neurosurg 2017; 129:1008-1016. [PMID: 29271714 DOI: 10.3171/2017.6.jns17188] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Subdural hematoma (SDH) is a common disease that is increasingly being managed nonoperatively. The all-cause readmission rate for SDH has not previously been described. This study seeks to describe the incidence of unexpected 30-day readmission in a cohort of patients admitted to an academic neurosurgical center. Additionally, the relationship between operative management, clinical outcome, and unexpected readmission is explored. METHODS This is an observational study of 200 consecutive adult patients with SDH admitted to the neurosurgical ICU of an academic medical center. Demographic information, clinical characteristics, and treatment strategies were compared between readmitted and nonreadmitted patients. Multivariable logistic regression, weighted by the inverse probability of receiving surgery using propensity scores, was used to evaluate the association between operative management and unexpected readmission. RESULTS Of 200 total patients, 18 (9%) died during hospitalization and were not included in the analysis. Overall, 48 patients (26%) were unexpectedly readmitted within 30 days. Sixteen patients (33.3%) underwent SDH evacuation during their readmission. Factors significantly associated with unexpected readmission were nonoperative management (72.9% vs 54.5%, p = 0.03) and female sex (50.0% vs 32.1%, p = 0.03). In logistic regression analysis weighted by the inverse probability of treatment and including likely confounders, surgical management was not associated with likelihood of a good outcome at hospital discharge, but was associated with significantly reduced odds of unexpected readmission (OR 0.19, 95% CI 0.08-0.49). CONCLUSIONS Over 25% of SDH patients admitted to an academic neurosurgical ICU were unexpectedly readmitted within 30 days. Nonoperative management does not affect outcome at hospital discharge but is significantly associated with readmission, even when accounting for the probability of treatment by propensity score weighted logistic regression. Additional research is needed to validate these results and to further characterize the impact of nonoperative management on long-term costs and clinical outcomes.
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Affiliation(s)
| | - Kyle M Sheehan
- Departments of2Neurosurgery and.,3Neurology, University of Michigan, Ann Arbor, Michigan; and
| | | | | | - James F Burke
- 3Neurology, University of Michigan, Ann Arbor, Michigan; and
| | - Venkatakrishna Rajajee
- Departments of2Neurosurgery and.,3Neurology, University of Michigan, Ann Arbor, Michigan; and
| | - Craig A Williamson
- Departments of2Neurosurgery and.,3Neurology, University of Michigan, Ann Arbor, Michigan; and
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Bartek J, Sjåvik K, Ståhl F, Kristiansson H, Solheim O, Gulati S, Sagberg LM, Förander P, Jakola AS. Surgery for chronic subdural hematoma in nonagenarians: A Scandinavian population-based multicenter study. Acta Neurol Scand 2017; 136:516-520. [PMID: 28382656 DOI: 10.1111/ane.12764] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2017] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Chronic subdural hematoma (cSDH) is a prevalent condition often seen in the elderly, with surgery being the treatment of choice when symptomatic. So far, few have explored the surgical outcomes in patients 90 years or older. The aim of this study was to investigate outcome after cSDH surgery in nonagenarians (≥90 y/o group) compared to younger adult patients (<90 y/o group). MATERIALS In a Scandinavian population-based cohort we conducted a retrospective review of 1,254 patients undergoing primary burr-hole procedures for cSDH between January 1, 2005 and December 31, 2010 at three neurosurgical centers. In a comparative analysis, the primary end-point was difference in hematoma recurrence rates between the ≥90 y/o and <90 y/o groups. The secondary end-points were differences in perioperative morbidity and mortality between groups. RESULTS 75 patients were 90 years or older. There was no significant difference in recurrences resulting in reoperation between the age groups (10.7% vs 13.6%, P=.47). There was also no significant difference in overall complication rate (4.1% vs 8.1%, P=.21) or severe complications (1.4% vs 2.0%, P=.68). There were three (4.0%) perioperative deaths within 30 days in the ≥90 y/o group and 40 (3.4%) in the <90 y/o group (P=.78). CONCLUSION Patients 90 years or older had similar rates of recurrence, perioperative morbidity and perioperative mortality as compared to younger patients. Age alone should not be a contraindication for surgery in patients with cSDH.
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Affiliation(s)
- J. Bartek
- Department of Clinical Neuroscience; Section for Neurosurgery; Karolinska Institutet and Department of Neurosurgery; Karolinska University Hospital; Stockholm Sweden
- Department of Neurosurgery; Copenhagen University Hospital Rigshospitalet; Copenhagen Denmark
| | - K. Sjåvik
- Department of Neurosurgery; University Hospital of North Norway; Tromsø Norway
| | - F. Ståhl
- Department of Clinical Neuroscience; Section for Neurosurgery; Karolinska Institutet and Department of Neurosurgery; Karolinska University Hospital; Stockholm Sweden
| | - H. Kristiansson
- Department of Clinical Neuroscience; Section for Neurosurgery; Karolinska Institutet and Department of Neurosurgery; Karolinska University Hospital; Stockholm Sweden
| | - O. Solheim
- Department of Neurosurgery; St.Olav University Hospital; Trondheim Norway
- Department of Neuroscience; Norwegian University of Science and Technology; Trondheim Norway
- Norwegian National Advisory Unit for Ultrasound and Image-Guided Therapy; St.Olav Hospital; Trondheim Norway
| | - S. Gulati
- Department of Neurosurgery; St.Olav University Hospital; Trondheim Norway
- Department of Neuroscience; Norwegian University of Science and Technology; Trondheim Norway
| | - L. M. Sagberg
- Department of Neurosurgery; St.Olav University Hospital; Trondheim Norway
- Department of Neuroscience; Norwegian University of Science and Technology; Trondheim Norway
- Norwegian National Advisory Unit for Ultrasound and Image-Guided Therapy; St.Olav Hospital; Trondheim Norway
| | - P. Förander
- Department of Clinical Neuroscience; Section for Neurosurgery; Karolinska Institutet and Department of Neurosurgery; Karolinska University Hospital; Stockholm Sweden
| | - A. S. Jakola
- Department of Neurosurgery; St.Olav University Hospital; Trondheim Norway
- Department of Neurosurgery; Sahlgrenska Univerity Hospital; Gothenburg Sweden
- Institute of Neuroscience and Physiology; University of Gothenburg; Sahlgrenska Academy; Gothenburg Sweden
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Role of antithrombotic therapy in the risk of hematoma recurrence and thromboembolism after chronic subdural hematoma evacuation: a population-based consecutive cohort study. Acta Neurochir (Wien) 2017; 159:2045-2052. [PMID: 28956170 PMCID: PMC5636853 DOI: 10.1007/s00701-017-3330-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 09/08/2017] [Indexed: 11/13/2022]
Abstract
Objective To establish the risk of recurrence in patients with chronic subdural hematoma (cSDH) on antithrombotic treatment (AT, i.e., antiplatelets and anticoagulants). Secondary end points were perioperative morbidity and mortality between groups (AT vs. no-AT group) and exploration if timing of resumption of AT treatment (i.e., prophylactic early vs. late resumption) influenced the occurrence of thromboembolism and hematoma recurrence. Materials In a population-based consecutive cohort, we conducted a retrospective review of 763 patients undergoing primary burr hole procedures for cSDH between January 1, 2005, and December 31, 2010, at the Karolinska University Hospital, Stockholm, Sweden. Early AT resumption was ≤30 days and late >30 days after the procedure. Results A total of 308/763 (40.4%) cSDH patients were on AT treatment at the time of diagnosis. There was no difference in cSDH recurrence within 3 months (11.0% vs. 12.0%, p = 0.69) nor was there any difference in perioperative mortality (4.0% vs. 2.0%, p = 0.16) between those using AT compared to those who were not. However, perioperative morbidity was more common in the AT group compared to no-AT group (10.7% vs. 5.1%, p = 0.003). Comparing early vs. late AT resumption, there was no difference with respect to recurrence (7.0% vs. 13.9%, p = 0.08), but more thromboembolism in the late AT resumption group (2.0% vs. 7.0%, p < 0.01). Conclusion In clinical practice, cSDH patients on AT therapy at the time of diagnosis have similar recurrence rates and mortality compared to those without AT therapy, but with higher morbidity. Early resumption was not associated with more recurrence, but with lower thromboembolic frequency. Early AT resumption seems favorable, and a prospective RCT is needed.
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Bacigaluppi S, Guastalli F, Bragazzi NL, Balestrino A, Bruzzi P, Zona G. Prognostic factors in chronic subdural hematoma: results from a monocentric consecutive surgical series of 605 patients. J Neurosurg Sci 2017; 65:14-23. [PMID: 28959873 DOI: 10.23736/s0390-5616.17.04103-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The study of age-related diseases like chronic subdural hematoma (CSDH) is of high interest, considered the general ageing of the population. This investigation aimed to identify the main clinical characteristics of CSDH patients, to evaluate the impact of the disease on quality of life, its treatment and comorbidities/complications and to compare our data with other surgical series published over the past 5 years. METHODS A retrospective cohort study including all consecutive patients operated for CSDH between January 1, 2006 and December 31, 2013 at the Unit of Neurosurgery of our hospital was carried out. RESULTS 605 patients were included in the study (66.0% male, mean age 77.5±10.5 years). History of brain trauma was reported in 65.6%. Common comorbidities were hypertension (59.0%), cardiopathies (36.0%), and previous stroke (23.6%). Clotting and coagulation alterations were present in 27.2% and 17.0%, respectively. In 24.0% of cases, the hematoma was bilateral. 17.3% had more than one surgery. Length of stay was of 14.8±10.1 days. Baseline Karnofsky Performance Score (KPS), presurgical KPS, and KPS at discharge were 87.7±14.9, 64.9 ±19.8 and 76.7±27.2, respectively. A complete recovery was observed in 62.9% of patients. Mortality rate during hospitalization was 7.4%. CONCLUSIONS The knowledge of clinical and surgical factors which might impact on the clinical outcomes could help to better manage patients with CSDH, which represents a surgically "simple" but, indeed, not trivial disease.
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Affiliation(s)
- Susanna Bacigaluppi
- Unit of Neurosurgery, Department of Neurosciences (DINOGMI), IRCCS San Martino University Hospital, University of Genoa, Genoa, Italy - .,Center of Excellence for Biomedical Research (CEBR), University of Genoa, Genoa, Italy -
| | - Fedra Guastalli
- Unit of Neurosurgery, Department of Neurosciences (DINOGMI), IRCCS San Martino University Hospital, University of Genoa, Genoa, Italy
| | - Nicola L Bragazzi
- Department of Health Sciences (DISSAL), School of Public Health, University of Genoa, Genoa, Italy
| | - Alberto Balestrino
- Unit of Neurosurgery, Department of Neurosciences (DINOGMI), IRCCS San Martino University Hospital, University of Genoa, Genoa, Italy
| | - Paolo Bruzzi
- Unit of Clinical Epidemiology, IRCCS San Martino University Hospital, University of Genoa, Genoa, Italy
| | - Gianluigi Zona
- Unit of Neurosurgery, Department of Neurosciences (DINOGMI), IRCCS San Martino University Hospital, University of Genoa, Genoa, Italy.,Center of Excellence for Biomedical Research (CEBR), University of Genoa, Genoa, Italy
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Hussain R, Afzal M, Joshi S, Dardis R, Siddique S, Beltechi R, Amit A, El-Maghraby H, Saxena A, Shad A. Factors affecting the survival following surgical treatment of chronic subdural haematoma: Single institutional experience. J Clin Neurosci 2017; 44:75-79. [PMID: 28687445 DOI: 10.1016/j.jocn.2017.06.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 06/18/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Chronic subdural haematoma (CSDH) is one of the most commonly treated condition in neurosurgery. It affects elderly populations who often have significant medical co-morbidities resulting in poor prognosis. The study aimed at identifying clinical factors influencing the survival following surgical management of CSDH. METHODS Retrospective study included 267 cases that underwent surgery for CSDH and followed over 5-year period (2010-2015); data retrieved with reference to operation details, radiology reports and discharge. Using logistic and Cox regression analysis, the patient survival data was analysed with respect to patient demographics, type of surgery, co-morbidities, anticoagulation treatment, and discharge destination. RESULTS The overall survival in the cohort was 37.0months (IQR: 20.0-60.0). The median age of the patients was 76years (IQR: 66-82) and the median length of hospital stay was 10days (range 1-126days; IQR: 6-17days). The recurrence rate was 6.37% (n=17). Fifty-three (19.85%) patients recorded deceased on the IPM database as of October 2016 and of those 11 died in hospital. Univariate Cox-regression analysis revealed increased age (HR: 1.80; 95%CI: 1.04-3.11), length of hospital stay (HR: 2.50; 95%CI: 1.41-4.41) and number of co-morbidities (HR: 2.19; 95%CI: 1.26-3.79) were associated with poor prognosis. Glasgow coma scale (GCS) at discharge was found to be significantly associated with survival whilst anticoagulation treatment did not. Multivariate analysis confirmed similar findings significant statistically. CONCLUSION Age at admission, median length of hospital stay, number of co-morbidities, GCS at discharge and discharge destination have been found to influence survival significant statistically.
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Affiliation(s)
- Rahim Hussain
- Department of Neurosurgery, University Hospital Coventry and Warwickshire, Coventry CV2 2DX, UK.
| | - Mohammed Afzal
- Department of Neurosurgery, University Hospital Coventry and Warwickshire, Coventry CV2 2DX, UK
| | - Shabin Joshi
- Department of Neurosurgery, University Hospital Coventry and Warwickshire, Coventry CV2 2DX, UK
| | - Ronan Dardis
- Department of Neurosurgery, University Hospital Coventry and Warwickshire, Coventry CV2 2DX, UK
| | - Shahid Siddique
- Department of Neurosurgery, University Hospital Coventry and Warwickshire, Coventry CV2 2DX, UK
| | - Radu Beltechi
- Department of Neurosurgery, University Hospital Coventry and Warwickshire, Coventry CV2 2DX, UK
| | - Amit Amit
- Department of Neurosurgery, University Hospital Coventry and Warwickshire, Coventry CV2 2DX, UK
| | - Hussein El-Maghraby
- Department of Neurosurgery, University Hospital Coventry and Warwickshire, Coventry CV2 2DX, UK
| | - Amar Saxena
- Department of Neurosurgery, University Hospital Coventry and Warwickshire, Coventry CV2 2DX, UK
| | - Amjad Shad
- Department of Neurosurgery, University Hospital Coventry and Warwickshire, Coventry CV2 2DX, UK
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Bapat S, Shapey J, Toma A, Platt L, Luoma AMV. Chronic subdural haematomas: a single-centre experience developing an integrated care pathway. Br J Neurosurg 2017; 31:434-438. [PMID: 28264594 DOI: 10.1080/02688697.2017.1297372] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To improve quality of care for patients presenting with chronic subdural haematoma (CSDH) by introducing a multi-disciplinary integrated care pathway. SUMMARY BACKGROUND CSDH is a common neurological condition. Incidence rises with age and currently affects around 58/100 000 people over 70 years. Six-month mortality is high (26%), however integrated care pathways have been shown to improve patient outcomes in other surgical subspecialties. MATERIALS AND METHODS A baseline retrospective audit completed in 2012 identified areas for improvement in patient management. Stakeholder meetings were held with subsequent development and implementation of a patient care pathway. A post-implementation prospective audit was completed between January and October 2015. DATA COLLECTED patient demographics, medical co-morbidities, use of anti-platelet and anti-coagulant medication, timing of surgery, length of hospital stay, morbidity and mortality data, and reaccumulation rate. RESULTS Patient groups were similar with a high incidence of multi-morbidity. The key areas targeted for improvement included enhanced pre-operative optimisation and time to surgery. Implementation of the patient care pathway significantly increased the number of patients undergoing surgery within 24 hours of admission (43% vs. 75%, p = 0.0006) but length of hospital stay did not change. Operative morbidity and mortality remained similar and there was no significant difference in CSDH reaccumulation rate. CONCLUSION Our patient care pathway appears to have improved pre-operative care and significantly increased the proportion of patients undergoing surgery within 24 hours of admission. Difficulties were encountered with changing existing practice. Prospective research is required to demonstrate the full benefits, which may include a reduction in health and social care costs.
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Affiliation(s)
- Smita Bapat
- a Department of Neuroanaesthesia , National Hospital for Neurology and Neurosurgery , London , UK
| | - Jonathan Shapey
- b Victor Horsley Department of Neurosurgery , National Hospital for Neurology and Neurosurgery , London , UK
| | - Ahmed Toma
- b Victor Horsley Department of Neurosurgery , National Hospital for Neurology and Neurosurgery , London , UK
| | - Louise Platt
- b Victor Horsley Department of Neurosurgery , National Hospital for Neurology and Neurosurgery , London , UK
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Unterhofer C, Hartmann S, Freyschlag CF, Thomé C, Ortler M. Severe head injury in very old patients: to treat or not to treat? Results of an online questionnaire for neurosurgeons. Neurosurg Rev 2017; 41:183-187. [PMID: 28220369 DOI: 10.1007/s10143-017-0833-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 02/06/2017] [Accepted: 02/08/2017] [Indexed: 11/29/2022]
Abstract
Due to the aging population, neurosurgeons are confronted with an increasing number of very old patients suffering from traumatic brain injury. Many of these patients present with an acute subdural hematoma. There is a lack of data on neurosurgical decision-making in elderly people. We investigated the importance of imaging criteria, patients' wishes, their surrogates' wishes, and patient demographics on treatment decisions chosen by neurosurgeons. An online questionnaire was sent to all German neurosurgical units via the German Society of Neurosurgery (DGNC). The survey was based on the reported case of an unconscious 81-year-old patient with an acute subdural hematoma and consisted of 13 questions. Of these questions, nine addressed indication and treatment plan and four evaluated the neurosurgeon's interest in gathering additional information on the patient's social environment and supposed patient's wishes or advance directive. Eighty-five percent of the interviewed neurosurgeons would perform an emergency operation in the presented case. Midline shift (84%), hematoma thickness (81%), and time between traumatic injury and treatment (81%) were considered to be the most important factors for surgical treatment. Gathering information on the social environment of the patient (66%) and discussion with family members (57%) were felt to be either unimportant. Neurosurgeons in Central Europe tend to treat acute subdural hematoma in very old patients based on imaging findings and according to mechanistic views. Social circumstances and patient wishes are considered to be less important. Education of the medical profession and the general public should aim to bring these factors into focus in the decision-making process.
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Affiliation(s)
- Claudia Unterhofer
- Department of Neurosurgery, Medical University of Innsbruck, 6020, Innsbruck, Austria.
| | - Sebastian Hartmann
- Department of Neurosurgery, Medical University of Innsbruck, 6020, Innsbruck, Austria
| | | | - Claudius Thomé
- Department of Neurosurgery, Medical University of Innsbruck, 6020, Innsbruck, Austria
| | - Martin Ortler
- Department of Neurosurgery, Medical University of Innsbruck, 6020, Innsbruck, Austria
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Abstract
Chronic subdural hematoma (cSDH) is a common condition, the frequency of which further increases due to an aging population and more frequent use of antithrombotic drugs. It leads to unspecific symptoms and neurological deficits and is usually treated surgically. Burr hole trepanation and twist drill craniostomy have become the therapeutic standards with craniotomy being rarely used for recurrent cases. Although recurrences are relatively common, in most cases a good outcome can be achieved even in the elderly; however, as cSDH is associated with other comorbidities, it is indicative of an increased morbidity and mortality. Controlled trials need to be carried out to determine whether pharmacological therapies can also be beneficial in addition to surgical treatment.
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MESH Headings
- Aged, 80 and over
- Anticoagulants/adverse effects
- Anticoagulants/therapeutic use
- Craniotomy
- Female
- Hematoma, Subdural, Chronic/diagnostic imaging
- Hematoma, Subdural, Chronic/etiology
- Hematoma, Subdural, Chronic/mortality
- Hematoma, Subdural, Chronic/surgery
- Humans
- Male
- Neurologic Examination/methods
- Platelet Aggregation Inhibitors/adverse effects
- Platelet Aggregation Inhibitors/therapeutic use
- Population Dynamics
- Prognosis
- Recurrence
- Risk Factors
- Tomography, X-Ray Computed/methods
- Trephining/methods
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Affiliation(s)
- T A Juratli
- Klinik und Poliklinik für Neurochirurgie, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland.
| | - J Klein
- Klinik und Poliklinik für Neurochirurgie, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland
| | - G Schackert
- Klinik und Poliklinik für Neurochirurgie, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstraße 74, 01307, Dresden, Deutschland
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Castro-Rodríguez C, Román-Pena P, Arán-Echabe E, Gelabert-González M. [Chronic subdural haematomas in very elderly patients]. Rev Esp Geriatr Gerontol 2016; 51:309-316. [PMID: 27345661 DOI: 10.1016/j.regg.2016.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 05/09/2016] [Accepted: 05/13/2016] [Indexed: 06/06/2023]
Abstract
INTRODUCTION Chronic subdural haematoma (CSDH) is one of the most common neurosurgical conditions and is especially prevalent among elderly individuals. The objective of this study was to analyse the demographic, clinical and radiological findings, and surgical outcomes in a series of chronic subdural haematoma in patients older than 85 years. PATIENTS AND METHODS A review was carried out on all patients over 85 years with CSDH treated in our neurosurgical service from April 1986 to November 2015. A record was made of the baseline patient characteristics (age, sex, comorbidities, known risk factors, imaging characteristics, and number of burr-holes) and surgical outcomes (complications, especially recurrences and mortality). An analysis was carried out on the special characteristics of these patients, as well as the relationships between gender, clinical grade, anti-platelet or anticoagulant therapy, internal architecture of the haematoma, and midline shift, with mortality and recurrence of the haematoma. RESULTS A total of 200 patients were included, with a mean age of 88.5 (range 85-104) years, and the male: female sex ratio was 1:1.1. History of injury was reported in 114 (57%) cases. Anti-platelet or anticoagulant therapy was being used by 71 (35.5%) patients. On admission, 114 patients (57%) were in satisfactory condition (Markwalder grades 0-2). The main symptom was behavioural disturbance in 82 (41%) cases. CSDH was left-sided in 89 (44.5%) patients, right-sided in 78 (39%) cases (39%), and bilateral in the remaining 33 (16.5%) cases). Postoperative complications were observed in 59 cases (29 recurrences). Preoperative Markwalder grade correlated significantly with recurrence rate and mortality (P<.0001). CONCLUSIONS CSDH was a very common disease in very elderly patients. Behavioural disturbance and neurological deficits are the most common first symptom. Preoperative neurological status at admission is the most important factor in recurrences and mortality.
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Affiliation(s)
| | - Paula Román-Pena
- Departamento de Cirugía, Universidad de Santiago de Compostela, Santiago de Compostela, España; Servicio de Neurocirugía, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, España
| | - Eduardo Arán-Echabe
- Departamento de Cirugía, Universidad de Santiago de Compostela, Santiago de Compostela, España; Servicio de Neurocirugía, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, España
| | - Miguel Gelabert-González
- Departamento de Cirugía, Universidad de Santiago de Compostela, Santiago de Compostela, España; Servicio de Neurocirugía, Complejo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, España.
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Lee SJ, Hwang SC, Im SB. Twist-Drill or Burr Hole Craniostomy for Draining Chronic Subdural Hematomas: How to Choose It for Chronic Subdural Hematoma Drainage. Korean J Neurotrauma 2016; 12:107-111. [PMID: 27857917 PMCID: PMC5110898 DOI: 10.13004/kjnt.2016.12.2.107] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Revised: 08/07/2016] [Accepted: 08/23/2016] [Indexed: 11/29/2022] Open
Abstract
Objective Although twist-drill craniostomy (TDC) has a number of procedural advantages and an equivalent outcome compared to burr hole craniostomy (BHC) for the treatment of chronic subdural hematomas (CSDHs), the latter technique remains the preferred method. We analyzed symptomatic CSDHs in whom TDC at the pre-coronal suture entry point (PCSEP) was the primary method for hematoma drainage and BHC on the parietal was the secondary option. Methods CSDHs in 86 consecutive patients were included. TDC at the PCSEP, which is 1 cm anterior to coronal suture at the level of the superior temporal line, was the primary operational technique when the hematoma thickness was suitable, and BHC was performed via the parietal when TDC was unreasonable or failed. The clinical feasibility and outcomes of these approaches were analyzed. Results Of the 86 patients, 68 (79.1%) were treated by TDC, and 18 (20.9%) by BHC. All patients showed improvements in their symptoms after hematoma drainage. Neither morbidity nor mortality was associated with either technique, and there were no differences in drainage days between the groups. Ten patients had bilateral hematomas and were treated using TDC. Two patients were not sufficiently treated by TDC and, as a result, BHC was applied. Only six hematomas (7% of 86 hematomas) exhibited insufficient thickness on the computed tomography to perform TDC. Conclusion When the hematoma was thick enough, a majority of the CSDHs were drained using TDC at the PCSEP as the first procedure, which was especially useful for bilateral hematomas and in elderly patients.
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Affiliation(s)
- Seong-Jong Lee
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Sun-Chul Hwang
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Soo Bin Im
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
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Kim DI, Kim JH, Kang HI, Moon BG, Kim JS, Kim DR. Impact of Time Interval between Trauma Onset and Burr Hole Surgery on Recurrence of Late Subacute or Chronic Subdural Hematoma. J Korean Neurosurg Soc 2016; 59:498-504. [PMID: 27651869 PMCID: PMC5028611 DOI: 10.3340/jkns.2016.59.5.498] [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: 03/29/2016] [Revised: 06/14/2016] [Accepted: 07/20/2016] [Indexed: 11/27/2022] Open
Abstract
Objective Although subdural hematoma (SDH) is commonly treatable by burr hole surgery in the late subacute or chronic stage, there is no clear consensus regarding appropriate management and exact predictive factors for postoperative recurrence also remain unclear. The aim of this study was to evaluate risk factors associated with recurrence of SDH that requires burr hole surgery in the late subacute or chronic stage. We also identified the appropriate timing of surgery for reducing the recurrence. Methods We retrospectively reviewed 274 patients with SDH in the late subacute or chronic stage treated with burr hole surgery in our hospital between January 2007 and December 2014. Excluding patients with acute intracranial complications or unknown time of trauma onset left 216 patients included in the study. Results Of 216 patients with SDH in the late subacute or chronic stage, recurrence was observed in 36 patients (16.7%). The timing of the operation in patients with late subacute stage (15–28 days) resulted in a significant decrease in recurrence (RR, 0.33; 95% CI, 0.17–0.65; p=0.001) compared to chronic stage (>28 days). Otherwise, no significant risk factors were associated with recurrences including comorbidities and surgical details. Conclusion The results indicated that time from trauma onset to burr hole surgery may be important for decreasing the risk of recurrence. Therefore, unless patients can be treated conservatively without surgery, prompt surgical management is recommended in patients diagnosed as having late subacute or chronic subdural hematoma treatable by burr hole surgery, even when neurological deficits are unclear.
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Affiliation(s)
- Dae-In Kim
- Department of Neurosurgery, Eulji General Hospital, College of Medicine, Eulji University, Seoul, Korea
| | - Jae-Hoon Kim
- Department of Neurosurgery, Eulji General Hospital, College of Medicine, Eulji University, Seoul, Korea
| | - Hee-In Kang
- Department of Neurosurgery, Eulji General Hospital, College of Medicine, Eulji University, Seoul, Korea
| | - Byung-Gwan Moon
- Department of Neurosurgery, Eulji General Hospital, College of Medicine, Eulji University, Seoul, Korea
| | - Joo-Seung Kim
- Department of Neurosurgery, Eulji General Hospital, College of Medicine, Eulji University, Seoul, Korea
| | - Deok-Ryeong Kim
- Department of Neurosurgery, Eulji General Hospital, College of Medicine, Eulji University, Seoul, Korea
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