The incidence of chronic subdural hematomas from 1990 to 2015 in a defined Finnish population

Advances in pathogenic mechanisms, diagnostic methods, surgical and non-surgical treatment, and potential recurrence factors of Chronic Subdural Hematoma: A review

Chronic Subdural Hematoma (CSDH) is a common hemorrhagic disease in neurosurgery, and with the intensification of global aging, its incidence is gradually increasing. With the advancement of scientific technology, the etiological concepts and surgical treatments for CSDH have continually evolved over time. Currently, neuroscientists' understanding of CSDH is no longer confined to bridging vein rupture; exploration of various mechanisms such as angiogenesis, maturation of blood vessels, and inflammation is also underway. In-depth exploration and discovery of pathogenic mechanisms guide the updating of clinical treatment strategies and methods. For different types of CSDH, there is now a clear guidance for the targeted selection of treatment methods. However, the current treatment of CSDH cannot completely solve all problems, and the updating of treatment methods as well as the development and validation of new effective drugs remain challenges for the future. In addition, the recurrence of CSDH is a significant issue that needs to be addressed. Although we have reviewed potential recurrent factors that may be associated, the strength of this evidence is insufficient. Future research should gradually focus on validating these recurrent factors and exploring new ones, in order to optimize the existing understanding and treatment of CSDH.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Additional treatment after primary conservative treatment in patients with chronic subdural hematoma-A retrospective study

OBJECTIVE

Chronic subdural hematoma (CSDH) is a common neurological condition and is typically treated with burr hole craniostomy. Nevertheless, conservative treatment may lead to spontaneous hematoma resolution in some patients. This study aims to describe the characteristics of patients who were treated conservatively without the eventual need for additional treatment.

METHODS

Data were retrospectively collected from patients who were primarily treated conservatively in three hospitals in the Netherlands from 2008 to 2018. The Primary outcome was the nonnecessity of additional treatment within 3 months after the initial CSDH diagnosis. We used univariable and multivariable logistic regression analyses to identify factors associated with not receiving additional treatment.

RESULTS

In this study, 83 patients were included and 61 patients (73%) did not receive additional treatment within 3 months. Upon first presentation, the patients had a Markwalder Grading Scale score (MGS) of 0 (n = 5, 6%), 1 (n = 43, 52%), and 2 (n = 35, 42%). Additional treatment was less often received by patients with smaller hematoma volumes (adjusted odds ratio [aOR] 0.78 per 10 mL; 95% confidence interval [CI] 0.64-0.92). Patients using antithrombotic medication also received less additional treatment, but this association was not significant (aOR 2.02; 95% CI 0.61-6.69).

CONCLUSIONS

Three quarters of the initially conservatively treated CSDH patients do not receive additional management. Typically, these patients have smaller hematoma volumes. Further, prospective research is needed to distinguish which patients require surgical intervention and in whom primary conservative treatment suffices.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

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

Single-cell sequencing analysis of chronic subdural hematoma cell subpopulations and their potential therapeutic mechanisms

BACKGROUND

Chronic subdural hematoma (CSDH) is a prevalent form of intracranial haemorrhage encountered in neurosurgical practice, and its incidence has notably risen in recent years. Currently, there is a lack of studies that have comprehensively classified the cells present in hematomas removed during surgery, and their correlation with CSDH recurrence remains elusive. This study aims to analyse the subcellular populations and occupancy levels within peripheral blood.

METHODS

This study analyses the subcellular populations and occupancy levels within peripheral blood and postoperatively removed hematomas by single-cell sequencing and attempts to analyse the effect of different cell occupancies within peripheral blood and intraoperatively removed hematomas on CSDH.

RESULTS

The single-cell sequencing results showed that the cells were classified into 25 clusters by differential gene and UMAP dimensionality reduction clustering analyses and further classified into 17 significant cell populations by cell markers: pDCs, CD8 T cells, CD4 T cells, MigDCs, cDC2s, cDC1s, plasma cells, neutrophils, naive B cells, NK cells, memory B cells, M2 macrophages, CD8 Teffs, CD8 MAIT cells, CD4 Tregs, CD19 B cells, and monocytes. Further research showed that the presence of more cDC2 and M2 macrophages recruited at the focal site in patients with CSDH and the upregulation of the level of T-cell occupancy may be a red flag for further brain damage. ROS, a marker of oxidative stress, was significantly upregulated in cDC2 cells and may mediate the functioning of transcription proteins of inflammatory factors, such as NFκB, which induced T cells' activation. Moreover, cDC2 may regulate M2 macrophage immune infiltration and anti-inflammatory activity by secreting IL1β and binding to M2 macrophage IL1R protein.

CONCLUSION

The detailed classification of cells in the peripheral blood and hematoma site of CSDH patients helps us to understand the mechanism of CSDH generation and the reduction in the probability of recurrence by regulating the ratio of cell subpopulations.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Acute-to-chronic subdural hematoma: radiographic and clinical progression from acute subdural hematoma

INTRODUCTION

The pathogenesis of chronic subdural hematoma (CSDH) has not been completely understood. However, different mechanisms can result in space-occupying subdural fluid collections, one pathway can be the transformation of an original trauma-induced acute subdural hematoma (ASDH) into a CSDH.

MATERIALS AND METHODS

All patients with unilateral CSDH, requiring burr hole trephination between 2018 and 2023 were included. The population was distributed into an acute-to-chronic group (group A, n = 41) and into a conventional group (group B, n = 282). Clinical and radiographic parameters were analyzed. In analysis A, changes of parameters after trauma within group A are compared. In analysis B, parameters between the two groups before surgery were correlated.

RESULTS

In group A, volume and midline shift increased significantly during the progression from acute-to-chronic (p < 0.001, resp.). Clinical performance (modified Rankin scale, Glasgow Coma Scale) dropped significantly (p = 0.035, p < 0.001, resp.). Median time between trauma with ASDH and surgery for CSDH was 12 days. Patients treated up to the 12th day presented with larger volume of ASDH (p = 0.012). Before burr hole trephination, patients in group A presented with disturbance of consciousness (DOC) more often (p = 0.002), however less commonly with a new motor deficit (p = 0.014). Despite similar midline shift between the groups (p = 0.8), the maximal hematoma width was greater in group B (p < 0.001).

CONCLUSION

If ASDH transforms to CSDH, treatment may become mandatory early due to increase in volume and midline shift. Close monitoring of these patients is crucial since DOC and rapid deterioration is common in this type of SDH.

Postoperative elevated bed header position versus supine in the management of chronic subdural hematoma: a systematic review and meta-analysis

BACKGROUND

Chronic subdural hematoma (CSDH) is a prevalent type of intracranial hemorrhage. Surgical interventions, such as Twist Drill Craniostomy and Burr Hole Craniostomy, are employed for its treatment. However, limited information exists regarding the impact of postoperative head position (supine vs. elevated) on clinical outcomes. We aim to assess whether patients' head position after surgery influences their prognosis.

METHOD

We conducted a PRISMA-compliant systematic review and meta-analysis. Our search encompassed PubMed, Cochrane CENTRAL, Scopus, Web of Science, and Embase databases to identify relevant published studies. Data were meticulously extracted, pooled using a fixed model, and reported as risk ratios (RR) with 95% confidence intervals (CI). Statistical analysis was performed using R and Stata MP v.17.

RESULTS

Five studies involving 284 patients were included in our meta-analysis. We focused on three primary clinical outcomes, comparing the supine and elevated header positions. Notably, there was no statistically significant difference between the supine and elevated positions in terms of recurrence rate (RR 0.77, 95% CI [0.44, 1.37]), second intervention for recurrence (RR 1.07, 95% CI [0.42, 2.78]) and postoperative complications (RR 1.16, 95% CI [0.70, 1.92]).

CONCLUSION

Current studies have proved no difference between supine and elevated bed header positions regarding recurrence rate, second intervention for recurrence, and postoperative complications. Future RCTs with long-term follow-ups are recommended.

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

Background

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

Methods

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

Results

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

Conclusion

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

ARISE I Consensus Statement on the Management of Chronic Subdural Hematoma

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

Advances in chronic subdural hematoma and membrane imaging

Chronic subdural hematoma (cSDH) is projected to become the most common cranial neurosurgical disease by 2030. Despite medical and surgical management, recurrence rates remain high. Recently, middle meningeal artery embolization (MMAE) has emerged as a promising treatment; however, determinants of disease recurrence are not well understood, and developing novel radiographic biomarkers to assess hematomas and cSDH membranes remains an active area of research. In this narrative review, we summarize the current state-of-the-art for subdural hematoma and membrane imaging and discuss the potential role of MR and dual-energy CT imaging in predicting cSDH recurrence, surgical planning, and selecting patients for embolization treatment.

Impact of antithrombotic agents on outcomes in patients requiring surgery for chronic subdural haematoma: a systematic review and meta-analysis

A chronic subdural haematoma (CSDH) is a collection of aged blood between the dura and the brain, typically treated with surgical evacuation. Many patients with CSDH have comorbidities requiring the use of antithrombotic medications. The optimal management of these medications in the context of CSDH remains unknown, as the risk of recurrence must be carefully weighed against the risk of vaso-occlusive events. To better understand these risks and inform the development of clinical practice guidelines, we conducted a systematic review and meta-analysis. A systematic review was conducted in accordance with the PRISMA guidelines, searching Medline and Embase databases. The study was registered with PROSPERO (CRD42023397061). A total of 44 studies were included, encompassing 1 prospective cohort study and 43 retrospective cohort studies. Pooled odds ratios (ORs) were calculated for CSDH recurrence and vaso-occlusive events in patients taking anticoagulant or antiplatelet medications compared to patients not receiving antithrombotic therapy. GRADE was used to assess the quality of evidence. In patients on anticoagulant therapy at CSDH diagnosis, the pooled OR for CSDH recurrence was 1.41 (95% CI 1.11 to 1.79; I2 = 28%). For patients on antiplatelet therapy, the pooled OR was 1.31 (95% CI 1.08 to 1.58; I2 = 32%). Patients taking antithrombotic medications had a significantly higher risk of vaso-occlusive events, with a pooled OR of 3.74 (95% CI 2.12 to 6.60; I2 = 0%). There was insufficient evidence to assess the impact of time to recommence antithrombotic medication on CSDH outcomes. We found that baseline antithrombotic use is associated with the risk of CSDH recurrence and vaso-occlusive events following surgical evacuation. The evidence base is of low quality, and decisions regarding antithrombotic therapy should be individualised for each patient. Further high-quality, prospective studies or registry-based designs are needed to better inform clinical decision-making and establish evidence-based guidelines.

Incidence of surgically treated chronic subdural hematoma after head injury with normal initial computed tomography

PURPOSE

The objective was to determine the incidence of surgically treated chronic subdural hematoma (cSDH) within six months after head trauma in a consecutive series of head injury patients with a normal initial computed tomography (CT).

METHODS

A total of 1941 adult patients with head injuries who underwent head CT within 48 h after injury and were treated at the Tampere University Hospital's emergency department were retrospectively evaluated from medical records (median age = 59 years, IQR = 39-79 years, males = 58%, patients using antithrombotic medication = 26%). Patients with no signs of acute traumatic intracranial pathology or any type of subdural collection on initial head CT were regarded as CT negative (n = 1573, 81%).

RESULTS

Two (n = 2) of the 1573 CT negative patients received surgical treatment for cSDH. Consequently, the incidence of surgically treated cSDH after a normal initial head CT during a six-month follow-up was 0.13%. Both patients sustained mild traumatic brain injuries initially. One of the two patients was on antithrombotic medication (warfarin) at the time of trauma, hence incidence of surgically treated cSDH among patients with antithrombotic medication in CT negative patients (n = 376, 23.9%) was 0.27%. Additionally, within CT negative patients, one subdural hygroma was operated shortly after trauma.

CONCLUSION

The extremely low incidence of surgically treated cSDH after a normal initial head CT, even in patients on antithrombotic medication, supports the notion that routine follow-up imaging after an initial normal head CT is not indicated to exclude the development of cSDH. Additionally, our findings support the concept of cSDH not being a purely head trauma-related disease.

Neovascularization in Outer Membrane of Chronic Subdural Hematoma : A Rationale for Middle Meningeal Artery Embolization

OBJECTIVE

Chronic subdural hematomas (cSDHs) are generally known to result from traumatic tears of bridging veins. However, the causes of repeat spontaneous cSDHs are still unclear. We investigated the changes in vasculature in the human dura mater and outer membrane (OM) of cSDHs to elucidate the cause of their spontaneous repetition.

METHODS

The dura mater was obtained from a normal control participant and a patient with repeat spontaneous cSDHs. The pathological samples from the patient included the dura mater and OM tightly adhered to the inner dura. The samples were analyzed with a particular focus on blood and lymphatic vessels by immunohistochemistry, 3-dimensional imaging using a transparent tissue clearing technique, and electron microscopy.

RESULTS

The dural border cell (DBC) layer of the dura mater and OM were histologically indistinguishable. There were 5.9 times more blood vessels per unit volume of tissue in the DBC layer and OM in the patient than in the normal control. The DBC layer and OM contained pathological sinusoidal capillaries not observed in the normal tissue; these capillaries were connected to the middle meningeal arteries via penetrating arteries. In addition, marked lymphangiogenesis in the periosteal and meningeal layers was observed in the patient with cSDHs.

CONCLUSION

Neovascularization in the OM seemed to originate from the DBC layer; this is a potential cause of repeat spontaneous cSDHs. Embolization of the meningeal arteries to interrupt the blood supply to pathological capillaries via penetrating arteries may be an effective treatment option.

Dural metastasis of prostate carcinoma mimicking intracranial hematoma: a case report and literature review

Dural metastases of prostate adenocarcinoma are an extremely rare complication and may mimic intracranial hematoma. Preoperatively diagnosis may be difficult due to similarities in symptoms and radiological appearance. We present a 65-year-old man admitted to the ED with a history of headache, nausea, vomiting, vertigo, diplopia, as well as numbness of his left lower extremity. Past medical history confirmed metastatic prostate cancer disease. After computed tomography and contrast computed tomography, the consulting radiologist diagnosed a chronic subdural hematoma. After burr hole trephination and dural opening, tumorous mass was detected. Histopathologic samples were taken. Histopathological examination was consistent with metastatic adenocarcinoma of the prostate. Although rare, dural metastases need to be included in oncological patients presenting in the ED with symptoms and radiological imaging suggesting hematoma. Both neurooncological and neurosurgical consultations are essential in order to apply the best treatment strategy.

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

BACKGROUND

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

CASE PRESENTATION

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

CONCLUSION

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

Efficacy of intraoperative irrigation with artificial cerebrospinal fluid in chronic subdural hematoma surgery: study protocol for a multicenter randomized controlled trial

BACKGROUND

The surgical techniques for treatment of chronic subdural hematoma (CSDH), a common neurosurgical condition, have been discussed in a lot of clinical literature. However, the recurrence proportion after CSDH surgery remains high, ranging from 10 to 20%. The standard surgical procedure for CSDH involves a craniostomy to evacuate the hematoma, but irrigating the hematoma cavity during the procedure is debatable. The authors hypothesized that the choice of irrigation fluid might be a key factor affecting the outcomes of surgery. This multicenter randomized controlled trial aims to investigate whether intraoperative irrigation using artificial cerebrospinal fluid (ACF) followed by the placement of a subdural drain would yield superior results compared to the placement of a subdural drain alone for CSDH.

METHODS

The study will be conducted across 19 neurosurgical departments in Japan. The 1186 eligible patients will be randomly allocated to two groups: irrigation using ACF or not. In either group, a subdural drain is to be placed for at least 12 h postoperatively. Similar to what was done in previous studies, we set the proportion of patients that meet the criteria for ipsilateral reoperation at 7% in the irrigation group and 12% in the non-irrigation group. The primary endpoint is the proportion of patients who meet the criteria for ipsilateral reoperation within 6 months of surgery (clinical worsening of symptoms and increased hematoma on imaging compared with the postoperative state). The secondary endpoints are the proportion of reoperations within 6 months, the proportion being stratified by preoperative hematoma architecture by computed tomography (CT) scan, neurological symptoms, patient condition, mortality at 6 months, complications associated with surgery, length of hospital stay from surgery to discharge, and time of the surgical procedure.

DISCUSSION

We present the study protocol for a multicenter randomized controlled trial to investigate our hypothesis that intraoperative irrigation with ACF reduces the recurrence proportion after the removal of chronic subdural hematomas compared with no irrigation.

TRIAL REGISTRATION

ClinicalTrials.gov jRCT1041220124. Registered on January 13, 2023.

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

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

Time-of-flight magnetic resonance angiography for detection of postoperative recurrence in patients with chronic subdural hematoma

PURPOSE

Chronic subdural hematoma (CSDH) is associated with postoperative recurrence. Although various factors are involved in postoperative recurrence of CSDH, blood flow, especially in the middle meningeal artery (MMA), is considered to play an important role. We investigated whether the degree of signal intensity (SI) of the MMA on time-of-flight magnetic resonance angiography (TOF MRA) and various clinical factors are involved in recurrence of CSDH.

METHODS

The maximum SI of both MMAs was measured on TOF MRA images within 1 month before or after the initial surgery.

RESULTS

In total, 185 patients (20 with and 165 without recurrence of CSDH) were included in the analysis. The SI ratio and dementia were significant predictors of recurrence of CSDH (SI ratio: odds ratio [95% confidence interval (CI)] = 1.71 [1.32, 2.22], p < 0.0001; dementia: odds ratio [95% CI] = 7.41 [1.83, 30.1], p = 0.005). The estimated regression coefficients in the final model were 6.14 for the SI ratio and 1.28 for dementia. The risk score was derived according to these regression coefficients as follows: score = 5 × SI ratio + 1 (dementia: yes). With a score of 5, the predicted probability of recurrence was 2% [95% CI 0.7, 5.7], whereas with scores of 8 and 10, the probability was 43.3% [27.0, 61.1] and 89.5% [65.7, 97.5], respectively, which increased the risk of recurrence.

CONCLUSION

Patients with an increased SI ratio of the affected MMA on TOF MRA who underwent surgery for CSDH were significantly more likely to experience recurrence.

Safety of middle meningeal artery embolization for treatment of subdural hematoma: A nationwide propensity score matched analysis

OBJECTIVE

Middle meningeal artery embolization (MMAe) has burgeoned as a treatment for chronic subdural hematoma (cSDH). This study evaluates the safety and short-term outcomes of MMAe patients relative to traditional treatment approaches.

METHODS

In this retrospective large database study, adult patients in the National Inpatient Sample from 2012-2019 with a diagnosis of cSDH were identified. Cost of admission, length of stay (LOS), discharge disposition, and complications were analyzed. Propensity score matching (PSM) was utilized.

RESULTS

A total of 123,350 patients with cSDH were identified: 63,450 without intervention, 59,435 surgery only, 295 MMAe only, and 170 surgery plus MMAe. On PSM analysis, MMAe did not increase the risk of inpatient complications or prolong the length of stay compared to conservative management (p>0.05); MMAe had higher cost ($31,170 vs. $10,768, p<0.001) than conservative management, and a lower rate of nonroutine discharge (53.8% vs. 64.3%, p=0.024). Compared to surgery, MMAe had shorter LOS (5 vs. 7 days, p<0.001), and lower rates of neurological complications (2.7% vs. 7.1%, p=0.029) and nonroutine discharge (53.8% vs. 71.7%, p<0.001). There was no significant difference in cost (p>0.05).

CONCLUSIONS

MMAe had similar LOS and decreased odds of adverse discharge with a modest cost increase compared to conservative management. There was no difference in inpatient complications. Compared to surgery, MMAe treatment was associated with decreased LOS and rates of neurological complications and nonroutine discharge. This nationwide analysis supports the safety of MMAe to treat cSDH.

Liquid embolic surface area as a predictor of chronic subdural hematoma resolution in middle meningeal artery embolization

BACKGROUND

Liquid embolic agents (LEAs) such as ethylene vinyl alcohol (EVOH) are utilized for middle meningeal artery embolization (MMAE) for chronic subdural hematomas (cSDH). LEAs may be advantageous for MMAE as they are permanent and can penetrate the microvasculature of the subdural membranes. LEA surface area (SA) can quantify this penetration. The segmentation of LEA SA is not described in the literature and may be of interest in refining MMAE technique.

METHODS

We retrospectively collected computerized tomography (CT) scans from 74 patients (with 95 cSDH) who underwent first-line MMAE with EVOH. Non-contrast head CTs were acquired pre-embolization, immediately post-embolization and at 1-, 3-, and 6 month follow-up. A 3D-Slicer was used to segment hematoma volumes and the liquid embolic cast. We hypothesized that greater LEA SA would be correlated with greater improvements in cSDH volumetric resolution.

RESULTS

There was significant resolution in cSDH volumes over the follow-up period compared to preoperative volume (p<0.0001). The LEA SA was significantly correlated with the rate of cSDH resolution at 3 months (R2=0.08, p=0.03), and 6 months (R2=0.14, p=0.01).

CONCLUSIONS

The correlation of LEA surface area with hematoma resolution at 3-months and 6-months suggests greater LEA penetration may improve radiographic outcomes. This study uniquely provides a quantitative radiological perspective on the effect of LEA penetration on cSDH resolution.

Standalone middle meningeal artery embolization versus middle meningeal artery embolization with concurrent surgical evacuation for chronic subdural hematomas: a multicenter propensity score matched analysis of clinical and radiographic outcomes

BACKGROUND

Middle meningeal artery embolization (MMAE) has emerged as a promising therapy for chronic subdural hematomas (cSDHs). The efficacy of standalone MMAE compared with MMAE with concurrent surgery is largely unknown.

METHODS

cSDH patients who underwent successful MMAE from 14 high volume centers with at least 30 days of follow-up were included. Clinical and radiographic variables were recorded and used to perform propensity score matching (PSM) of patients treated with standalone MMAE or MMAE with concurrent surgery. Multivariable logistic regression models were used for additional covariate adjustments. The primary outcome was recurrence requiring surgical rescue, and the secondary outcome was radiographic failure defined as <50% reduction of cSDH thickness.

RESULTS

722 MMAE procedures in 588 cSDH patients were identified. After PSM, 230 MMAE procedures remained (115 in each group). Median age was 73 years, 22.6% of patients were receiving anticoagulation medication, and 47.9% had no preoperative functional disability. Median midline shift was 4 mm and cSDH thickness was 16 mm, representing modestly sized cSDHs. Standalone MMAE and MMAE with surgery resulted in similar rates of surgical rescue (7.8% vs 13.0%, respectively, P=0.28; adjusted OR (aOR 0.73 (95% CI 0.20 to 2.40), P=0.60) and radiographic failure (15.5% vs 13.7%, respectively, P=0.84; aOR 1.08 (95% CI 0.37 to 2.19), P=0.88) with a median follow-up duration of 105 days. These results were similar across subgroup analyses and follow-up durations.

CONCLUSIONS

Standalone MMAE led to similar and durable clinical and radiographic outcomes as MMAE combined with surgery in select patients with moderately sized cSDHs and mild clinical disease.

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

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

[Traumatic brain injury]

Traumatic brain injury (TBI) describes parenchymal brain damage caused by external forces to the head. It has a massive personal and socioeconomic impact, as it is a disease with high morbidity and mortality. Both young and old people are affected, as a result of traffic or sports accidents as well as due to falls at home. The term TBI encompasses various clinical pictures, differing considerably in cause, prognosis and therapy. What they all have in common is the pathophysiological cascade that develops immediately after the initial trauma and which can persist for several days and weeks. In this phase, medical treatment, whether surgical or pharmacological, attempts to reduce the consequences of the primary damage. The aim is to maintain adequate cerebral perfusion pressure and to reduce intracranial pressure.

Craniocervical Manual Lymphatic Drainage Increases the Efficiency of Atorvastatin-Based Treatment of Chronic Subdural Hematoma

The objective of this study is to explore whether craniocervical manual lymphatic drainage (cMLD) can promote hematoma absorption and increase the efficiency of atorvastatin-based conservative treatment in chronic subdural hematoma (CSDH) patients. All CSDH patients treated with atorvastatin-based therapy between October 2020 and February 2022 in our department were retrospectively screened for enrollment. The patients were divided into the control and cMLD groups according to whether cMLD was performed. Head CT or MR images in both groups were obtained before the treatment and 2 weeks and 4 weeks after the treatment. MR images of the deep cervical lymphatic nodes (dCLNs) in 23 patients were obtained in the cMLD group before and approximately 2 weeks after treatment. The volumes of the dCLNs and hematoma were calculated. The primary outcomes are the differences in hematoma volume reduction after 4 weeks of treatment. The secondary outcomes were (1) the differences in hematoma volume reduction between the patients in these two groups in the 2nd week, (2) the dCLN volume change in the cMLD group before and after 2 weeks of treatment, and (3) the percentage of patients who transitioned to surgery because of failure to the conservative treatment. A total of 106 consecutive patients were enrolled in this study for analysis; 54 patients received atorvastatin-based treatment (control group), and 52 were treated with both atorvastatin-based treatment and cMLD (cMLD group). At baseline, the mean hematoma volume was 76.53 ± 42.97 ml in the control group and 88.57 ± 49.01 ml in the cMLD group (p = 0.181). In the 4th week, the absolute number of hematoma reductions (20.79 ± 34.73 ml vs. 37.28 ± 28.24 ml, p = 0.009) and percentage of hematoma reductions (22.58% ± 60.01% vs. 46.43% ± 30.12%, p = 0.012) in the cMLD group were greater than those in the control group. After 2 weeks of treatment, the absolute number of hematoma reductions showed no difference in the two groups, while the percentage of hematoma reduction was higher in the cMLD group (18.18% ± 24.61% vs. 2.08% ± 25.72%, p = 0.001). One patient in cMLD and 8 patients in the control group were transitioned to receive surgical treatment. The dCLN volumes in 23 experimental patients increased significantly after 2 weeks of treatment in the cMLD group (p = 0.032). There were no severe side effects that needed to be reported. Combined with atorvastatin-based therapy, cMLD can promote hematoma absorption and decrease the surgery rate, which provides a new therapeutic strategy for CSDH.

Factors Associated With Short-Term Outcomes of Burr-Hole Craniostomy Associated With Brain Re-Expansion and Subdural Hematoma Shrinkage for Chronic Subdural Hematoma

Objective

Chronic subdural hematoma (CSDH) is a commonly encountered neurosurgical pathology that frequently requires surgical intervention. With an increasingly aging demographic, more older people and patients with comorbidities will present with symptomatic CSDH. This study evaluated clinical and laboratory factors affecting the short-term outcomes of CSDH after surgical intervention.

Methods

We retrospectively analyzed 170 patients who underwent burr-hole trephination for CSDH in a single institution from January 2019 to December 2021. All patients were examined for risk factors and evaluated for hematoma thickness change and midline shifting on brain computed tomography (CT) scans at 3 days after burr-hole trephination.

Results

This consecutive series of patients included 114 males (67.1%) and 56 females (32.9%); mean age 72.4±12.5 years. Renal disease (p=0.044) and prior intracranial hemorrhage (p=0.004) were clinical factors associated with poorer prognosis. A statistically significant association was found between initial laboratory findings, including high creatine kinase (p=0.025) and low platelet (p=0.036) levels, and CT findings 3 days postoperatively. The 3-day mean arterial pressure and postoperative ambulation were not significantly associated with outcomes.

Conclusion

Burr-hole craniostomy is an effective surgical procedure for initial CSDH. However, patients with a history intracranial hemorrhage and abnormal laboratory findings, such as low platelet levels, who underwent burr-hole trephination had poor short-term outcomes. Therefore, these patients should be carefully monitored.

Comparison of surgical strategies in patients with chronic subdural haematoma: a protocol for a network meta-analysis

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.

Does a negative correlation of heme oxygenase-1 with hematoma thickness in chronic subdural hematomas affect neovascularization and microvascular leakage? A retrospective study with preliminary validation

OBJECTIVE

Chronic subdural hematoma (CSDH) is a common neurological disease among elderly adults. The progression of CSDH is an angiogenic process, involving inflammatory mediators that affect vascular permeability, microvascular leakage, and hematoma thickness. The authors aimed to identify biomarkers associated with angiogenesis and vascular permeability that might influence midline shift and hematoma thickness.

METHODS

Medical records and laboratory data of consecutive patients who underwent surgery for CSDH were analyzed. Collected data were basic demographic data, CSDH classification, CSDH thickness, midline shift, heme oxygenase-1 (HO-1) levels in hematomas, and common laboratory markers. Linear regression analysis was used to evaluate the relationship of CSDH thickness with characteristic variables. The chick chorioallantoic membrane (CAM) assay was used to test the angiogenic potency of identified variables in ex ovo culture of chick embryos.

RESULTS

In total, 93 patients with CSDH (71.0% male) with a mean age of 71.0 years were included. The mean CSDH thickness and midline shift were 19.7 and 9.8 mm, respectively. The mean levels of HO-1, ferritin, total bilirubin, white blood cells, segmented neutrophils, lymphocytes, platelets, international normalized ratio, and partial thromboplastin time were 36 ng/mL, 14.8 μg/mL, 10.5 mg/dL, 10.3 × 103 cells/μL, 69%, 21.7%, 221.1 × 109 cells/μL, 1.0, and 27.8 seconds, respectively. Pearson correlation analysis revealed that CSDH thickness was positively correlated with midline shift distance (r = 0.218, p < 0.05) but negatively correlated with HO-1 concentration (r = -0.364, p < 0.01) and ferritin level (r = -0.222, p < 0.05). Multivariate linear regression analysis revealed that HO-1 was an independent predictor of CSDH thickness (β = -0.084, p = 0.006). The angiogenic potency of HO-1 in hematoma fluid was tested with the chick CAM assay; topical addition of CSDH fluid with low HO-1 levels promoted neovascularization and microvascular leakage. Addition of HO-1 in a rescue experiment inhibited CSDH fluid-mediated angiogenesis and microvascular leakage.

CONCLUSIONS

HO-1 is an independent risk factor in CSDH hematomas and is negatively correlated with CSDH thickness. HO-1 may play a role in the pathophysiology and development of CSDH, possibly by preventing neovascularization and reducing capillary fragility and hyperpermeability.

Non-surgical patient characteristics best predict outcome after 6 months in patients surgically treated for chronic subdural haematoma

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.

Intraoperative irrigation of artificial cerebrospinal fluid and temperature of irrigation fluid for chronic subdural hematoma: a systematic review and meta-analysis

Purpose

To systematically review the different types of irrigation fluid and the different temperatures of irrigation fluid on postoperative recurrence rates in the evacuation of chronic subdural hematoma (CSDH).

Methods

We conducted a comprehensive search of electronic databases, including PubMed, Embase, the Cochrane Library, the China National Knowledge Infrastructure (CNKI), WanFang, the Chinese VIP Information (VIP), and China Biology Medicine (CBM), and reference lists of relevant studies to identify all eligible studies. Two reviewers independently screened the titles and abstracts for inclusion, and the full-text articles were assessed for eligibility based on predetermined inclusion and exclusion criteria. Data were extracted using a standardized form, and the quality of the studies was assessed using a risk of bias tool. Meta-analyses were performed using a fixed-or random-effects model, and heterogeneity was assessed using the I2 statistic. The primary endpoint was the postoperative recurrence rate.

Results

After stringent screening, a total of 11 studies were identified, including six English publications, four Chinese publications, and one Japanese publication, involving a population of 29,846 patients. Our meta-analysis provides evidence that artificial cerebrospinal fluid (ACF) could decrease the post-operative recurrence rate by 47% after the evacuation of CSDH when compared to normal saline (NS) [(odds ratio) OR 0.53, 95% confidence intervals (CI): 0.31-0.90, p = 0.02, I² = 67%]. Besides, the irrigation fluid at body temperature could decrease the postoperative recurrence rate of CSDH by 64% when compared to room temperature (OR = 0.36, 95% CI = 0.22-0.59, p < 0.0001, I² = 0%).

Conclusion

Our analysis revealed significant difference in the choice of irrigation fluid for CSDH surgery. Notably, we found that irrigation with fluid at body temperature demonstrated superiority over irrigation with fluid at room temperature, resulting in fewer instances of recurrence. This straightforward technique is both safe and widely available, providing an opportunity to optimize outcomes for patients with CSDH. Our findings suggest that the use of body-temperature NS or ACF of room temperature during operation should be considered a standard of procedure in CSDH surgery. Nevertheless, whether the different temperature of ACF could be considered a standard of procedure in CSDH surgery still need high-quality RCTs to further identify.

Systematic review registration

https://www.crd.york.ac.uk/prospero/; Identifier CRD42023424344.

Burr hole locations are associated with recurrence in single burr hole drainage surgery for chronic subdural hematoma

Background

Various factors have been reported as risk factors for chronic subdural hematomas (CSDH) recurrence. However, few studies have quantitatively evaluated the impact of CSDH locations and burr hole positions on recurrence. This study aimed to reveal the relation between CSDH recurrence and the locations of CSDH and burr holes.

Methods

Initial single burr hole surgeries for CSDH with a drainage tube between April 2005 and October 2021 at Otemae Hospital were enrolled. Patients' medical records, CSDH volume, and CSDH computed tomography values (CTV) were evaluated. The locations of CSDH and burr holes were assessed using Montreal Neurological Institute coordinates.

Results

A total of 223 patients were enrolled, including 34 patients with bilateral CSDH, resulting in 257 surgeries investigated. The rate of CSDH recurrence requiring reoperation (RrR) was 13.5%. The RrR rate was significantly higher in patients aged ≥76 years, those with bilateral CSDH, and those with postoperative hemiplegia. In RrR, the preoperative CSDH volume was significantly larger, and CTV was significantly smaller. The locations of CSDH had no influence on recurrence. However, in RrR, the locations of burr holes were found to be more lateral and more ventral. Multivariate Cox proportional hazards regression analysis showed that bilateral CSDH, more ventral burr hole positions, and postoperative hemiplegia were risk factors for recurrence.

Conclusions

The locations of burr holes are associated with CSDH recurrence. In RrR, CSDH profiles tend to show a larger volume and reduced CTV. Hemiplegia after burr hole surgery serves as a warning sign for RrR.

Middle meningeal artery embolization for symptomatic chronic subdural hematoma in the setting of severe transfusion-refractory thrombocytopenia: A case study and review of literature

Background

Surgical decompression for the treatment of chronic subdural hematomas (cSDHs) is irrefutably effective; however, its utility in managing cSDH in patients with comorbid coagulopathy remains controversial. The optimal threshold for platelet transfusion in cSDH management is <100,000/mm³, according to guidelines from the American Association of Blood Banks GRADE framework. This threshold may be unachievable in refractory thrombocytopenia, though surgical intervention may still be warranted. We present a patient with symptomatic cSDH and transfusion-refractory thrombocytopenia successfully treated with middle meningeal artery embolization (eMMA). We also review the literature to identify management approaches for cSDH with severe thrombocytopenia.

Case Description

A 74-year-old male with acute myeloid leukemia presented to the emergency department with persistent headache and emesis following fall without head trauma. Computed tomography (CT) revealed a 12 mm right-sided, mixed density SDH. Platelets were <2000/mm³ initially, which stabilized to 20,000 following platelet transfusions. He then underwent right eMMA without surgical evacuation. He received intermittent platelet transfusions with platelet goal >20,000 and was discharged on hospital day 24 with resolving SDH on CT.

Conclusion

High-risk surgical patients with refractory thrombocytopenia and symptomatic cSDH may be successfully treated with eMMA without surgical evacuation. A platelet goal of 20,000/mm³ before and following surgical intervention proved beneficial for our patient. Similarly, a literature review of seven cases of cSDH with comorbid thrombocytopenia revealed five patients undergoing surgical evacuation following initial medical management. Three cases reported a platelet goal of 20,000. All seven cases resulted in stable or resolving SDH with platelets >20,000 at discharge.

Dexamethasone versus Surgery for Chronic Subdural Hematoma

BACKGROUND

The role of glucocorticoids without surgical evacuation in the treatment of chronic subdural hematoma is unclear.

METHODS

In this multicenter, open-label, controlled, noninferiority trial, we randomly assigned symptomatic patients with chronic subdural hematoma in a 1:1 ratio to a 19-day tapering course of dexamethasone or to burr-hole drainage. The primary end point was the functional outcome at 3 months after randomization, as assessed by the score on the modified Rankin scale (range, 0 [no symptoms] to 6 [death]). Noninferiority was defined by a lower limit of the 95% confidence interval of the odds ratio for a better functional outcome with dexamethasone than with surgery of 0.9 or more. Secondary end points included scores on the Markwalder Grading Scale of symptom severity and on the Extended Glasgow Outcome Scale.

RESULTS

From September 2016 through February 2021, we enrolled 252 patients of a planned sample size of 420; 127 were assigned to the dexamethasone group and 125 to the surgery group. The mean age of the patients was 74 years, and 77% were men. The trial was terminated early by the data and safety monitoring board owing to safety and outcome concerns in the dexamethasone group. The adjusted common odds ratio for a lower (better) score on the modified Rankin scale at 3 months with dexamethasone than with surgery was 0.55 (95% confidence interval, 0.34 to 0.90), which failed to show noninferiority of dexamethasone. The scores on the Markwalder Grading Scale and Extended Glasgow Outcome Scale were generally supportive of the results of the primary analysis. Complications occurred in 59% of the patients in the dexamethasone group and 32% of those in the surgery group, and additional surgery was performed in 55% and 6%, respectively.

CONCLUSIONS

In a trial that involved patients with chronic subdural hematoma and that was stopped early, dexamethasone treatment was not found to be noninferior to burr-hole drainage with respect to functional outcomes and was associated with more complications and a greater likelihood of later surgery. (Funded by the Netherlands Organization for Health Research and Development and others; DECSA EudraCT number, 2015-001563-39.).

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

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

Modified Valsalva maneuver after burr-hole drainage of chronic subdural hematomas: A single-center cohort study

Background

Previous studies on the management of chronic subdural hematoma (cSDH) mainly focused on the risk of postoperative recurrence and measures to prevent it. In this study, we propose the use of a non-invasive postoperative treatment method, the modified Valsalva maneuver (MVM), as a means of reducing the recurrence of cSDH. This study aims to clarify the effects of MVM on functional outcomes and recurrence rates.

Methods

A prospective study was conducted at the Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology from November 2016 to December 2020. The study included 285 adult patients who underwent burr-hole drainage for the treatment of cSDH and received subdural drains. These patients were divided into two groups: the MVM group (n = 117) and the control group (n = 98). In the MVM group, patients received treatment with a customized MVM device for at least 10 times per hour, 12 h per day. The study's primary endpoint was the recurrence rate of SDH, while functional outcomes and morbidity 3 months after surgery were the secondary outcomes.

Results

In the current study, 9 out of 117 patients (7.7%) in the MVM group experienced a recurrence of SDH, while 19 out of 98 patients (19.4%, p < 0.05) in the HC group experienced a recurrence of SDH. Additionally, the infection rate of diseases such as pneumonia (1.7%) was significantly lower in the MVM group compared to the HC group (9.2%, p < 0.001, odds ratio (OR = 0.1). After 3 months of the surgery, 109 out of 117 patients (93.2%) in the MVM group achieved a favorable prognosis, compared to 80 out of 98 patients (81.6%) in the HC group (p = 0.008, with an OR of 2.9). Additionally, infection rate (with an OR of 0.2) and age (with an OR of 0.9) are independent predictors of a favorable prognosis at the follow-up stage.

Conclusions

The use of MVM in the postoperative management of cSDHs has been shown to be safe and effective, resulting in reduced rates of cSDH recurrence and infection following burr-hole drainage. These findings suggest that MVM treatment may lead to a more favorable prognosis at the follow-up stage.

Predicting neurosurgical referral outcomes in patients with chronic subdural hematomas using machine learning algorithms - A multi-center feasibility study

Background

Chronic subdural hematoma (CSDH) incidence and referral rates to neurosurgery are increasing. Accurate and automated evidence-based referral decision-support tools that can triage referrals are required. Our objective was to explore the feasibility of machine learning (ML) algorithms in predicting the outcome of a CSDH referral made to neurosurgery and to examine their reliability on external validation.

Methods

Multicenter retrospective case series conducted from 2015 to 2020, analyzing all CSDH patient referrals at two neurosurgical centers in the United Kingdom. 10 independent predictor variables were analyzed to predict the binary outcome of either accepting (for surgical treatment) or rejecting the CSDH referral with the aim of conservative management. 5 ML algorithms were developed and externally tested to determine the most reliable model for deployment.

Results

1500 referrals in the internal cohort were analyzed, with 70% being rejected referrals. On a holdout set of 450 patients, the artificial neural network demonstrated an accuracy of 96.222% (94.444-97.778), an area under the receiver operating curve (AUC) of 0.951 (0.927-0.973) and a brier score loss of 0.037 (0.022-0.056). On a 1713 external validation patient cohort, the model demonstrated an AUC of 0.896 (0.878-0.912) and an accuracy of 92.294% (90.952-93.520). This model is publicly deployed: https://medmlanalytics.com/neural-analysis-model/.

Conclusion

ML models can accurately predict referral outcomes and can potentially be used in clinical practice as CSDH referral decision making support tools. The growing demand in healthcare, combined with increasing digitization of health records raises the opportunity for ML algorithms to be used for decision making in complex clinical scenarios.

Effect of Irrigation Fluid Temperature on Recurrence in the Evacuation of Chronic Subdural Hematoma: A Randomized Clinical Trial

Importance

The effect of a physical property of irrigation fluid (at body vs room temperature) on recurrence rate in the evacuation of chronic subdural hematoma (cSDH) needs further study.

Objective

To explore whether irrigation fluid temperature has an influence on cSDH recurrence.

Design, Setting, and Participants

This was a multicenter randomized clinical trial performed between March 16, 2016, and May 30, 2020. The follow-up period was 6 months. The study was conducted at 3 neurosurgical departments in Sweden. All patients older than 18 years undergoing cSDH evacuation during the study period were screened for eligibility in the study.

Interventions

The study participants were randomly assigned by 1:1 block randomization to the cSDH evacuation procedure with irrigation fluid at room temperature (RT group) or at body temperature (BT group).

Main Outcomes and Measures

The primary end point was recurrence requiring reoperation within 6 months. Secondary end points were mortality, health-related quality of life, and complication frequency.

Results

At 6 months after surgery, 541 patients (mean [SD] age, 75.8 [9.8] years; 395 men [73%]) had a complete follow-up according to protocol. There were 39 of 277 recurrences (14%) requiring reoperation in the RT group, compared with 16 of 264 recurrences (6%) in the BT group (odds ratio, 2.56; 95% CI, 1.38-4.66; P < .001). There were no significant differences in mortality, health-related quality of life, or complication frequency.

Conclusions and Relevance

In this study, irrigation at body temperature was superior to irrigation at room temperature in terms of fewer recurrences. This is a simple, safe, and readily available technique to optimize outcome in patients with cSDH. When irrigation is used in cSDH surgery, irrigation fluid at body temperature should be considered standard of care.

Trial Registration

ClincalTrials.gov Identifier: NCT02757235.

Management of Chronic Subdural Hematoma: A Systematic Review and Component Network Meta-analysis of 455 Studies With 103 645 Cases

BACKGROUND

Chronic subdural hematoma (CSDH) is a common neurosurgical condition with a high risk of recurrence after treatment.

OBJECTIVE

To assess and compare the risk of recurrence, morbidity, and mortality across various treatments for CSDH.

METHODS

A systematic review and meta-analysis was performed. PubMed/MEDLINE, EMBASE, SCOPUS, and Web of Science were searched from January 01, 2000, to July 07, 2021. The primary outcome was recurrence, and secondary outcomes were morbidity and mortality. Component network meta-analyses (CNMAs) were performed for surgical and medical treatments, assessing recurrence and morbidity. Incremental risk ratios (iRRs) with 95% CIs were estimated for each component.

RESULTS

In total, 12 526 citations were identified, and 455 studies with 103 645 cases were included. Recurrence occurred in 11 491/93 525 (10.8%, 95% CI 10.2-11.5, 418 studies) cases after surgery. The use of a postoperative drain (iRR 0.53, 95% CI 0.44-0.63) and middle meningeal artery embolization (iRR 0.19, 95% CI 0.05-0.83) reduced recurrence in the surgical CNMA. In the pharmacological CNMA, corticosteroids (iRR 0.47, 95% CI 0.36-0.61) and surgical intervention (iRR 0.11, 95% CI 0.07-0.15) were associated with lower risk. Corticosteroids were associated with increased morbidity (iRR 1.34, 95% CI 1.05-1.70). The risk of morbidity was equivalent across surgical treatments.

CONCLUSION

Recurrence after evacuation occurs in approximately 10% of cSDHs, and the various surgical interventions are approximately equivalent. Corticosteroids are associated with reduced recurrence but also increased morbidity. Drains reduce the risk of recurrence, but the position of drain (subdural vs subgaleal) did not influence recurrence. Middle meningeal artery embolization is a promising treatment warranting further evaluation in randomized trials.

Chronic subdural hematoma recurrence due to contralateral neovascularization following middle meningeal artery embolization

INTRODUCTION

Chronic subdural hematoma (CSDH) is one of the most commonly encountered neurosurgical diseases. Middle meningeal artery embolization (MMAE) is a technique for the management of CSDH that has elicited promising results. Despite the encouraging results of MMAE, recurrence does occur. One uncommon mechanism for recurrence of CSDH is by means of neovascularization of the contralateral middle meningeal artery (MMA). We describe two cases of CSDH recurrence by means of contralateral middle meningeal artery neovascularization treated with contralateral MMAE.

METHODS

We identified two cases of recurrent subdural hematoma secondary to neovascularization following treatment with contralateral MMAE.

RESULTS

Two patients initially treated with MMAE were identified with CSDH recurrence secondary to contralateral MMA neovascularization. There was no traumatic or coagulopathic contribution to CSDH recurrence. In both cases, patients underwent contralateral MMAE. Both patients were neurologically intact with radiographic improvement of CSDH at follow up.

CONCLUSIONS

Re-accumulation of SDH following MMAE by means of contralateral MMA neovascularization is a rare subtype of subdural hematoma (SDH) recurrence following MMAE. Within the context of re-accumulation of SDH following MMAE, catheter angiography is an important diagnostic investigation to elucidate the etiology of the recurrence. Furthermore, when angiography reveals neovascularization of the contralateral MMA, embolization of the contralateral MMA achieves good clinical and radiographic result.

Swedish trial on embolization of middle meningeal artery versus surgical evacuation in chronic subdural hematoma (SWEMMA)—a national 12-month multi-center randomized controlled superiority trial with parallel group assignment, open treatment allocation and blinded clinical outcome assessment

Background

Chronic subdural hematoma (cSDH) is one of the most common neurosurgical disorders and the incidence is rising. The routine treatment is neurosurgical hematoma evacuation, which is associated with recurrence rates up to 10–25%. In recent years, endovascular embolization of the middle meningeal artery (eMMA) has garnered much attention due to recurrence rates as low as < 5%. Several randomized controlled trials are planned or ongoing. In most of these trials, conventional neurosurgical treatment with or without adjunctive endovascular embolization is compared. The proposed trial aims to conduct a head-to-head comparison between neurosurgical and endovascular treatment as stand-alone treatments.

Methods

The trial is academically driven and funded within existing public healthcare systems and infrastructure. Patients with uni- or bilateral cSDH, presenting with mild-to moderate symptoms, and admitted to neurosurgery on clinical grounds will be offered participation. Subjects are randomized 1:1 between conventional neurosurgical treatment (control) and endovascular embolization of the middle meningeal artery (intervention). Primary endpoint is reoperation due to clinically and/or radiologically significant recurrence within 3 months. Secondary endpoints include safety, technical success rate, neurological disability, and quality of life.

Discussion

There are mounting retrospective data suggesting eMMA, as sole treatment or as an adjunctive to neurosurgery for cSDH, is safe and effective with a reoperation rate lower than neurosurgical hematoma evacuation alone. If randomized controlled trials confirm these findings, there is a potential for a paradigm shift in the treatment of cSDH where a minimally invasive procedure can replace open surgery in a large and oftentimes old and fragile patient cohort.

Trial registration

ClinicalTrials.gov, ClinicalTrials.gov Identifier NCT05267184. Registered March 4, 2022.

Chronic Subdural Hematoma-Evolution of Etiology and Surgical Treatment

In this paper, I review the historical changes in the etiological concepts and surgical treatments for chronic subdural hematoma (CSDH) across the world and in Japan. I also examine future problems associated with its surgical procedures and medical costs. CSDH was first reported by Wepfer in 1657 as "delayed apoplexy." In 1857, Virchow described the famous concept of so-called "pachymeningitis hemorrhagica interna." He considered that the etiology of CSDH involved inflammation. In 1914, Trotter described the origin of CSDH as traumatic. Currently, CSDH is considered to arise with a first leak of blood from dural border cells after mild trauma. Inflammatory cells are then drawn to the border cell layer. At this point, new membranes form from activated inflammation; then, the hematoma enlarges, promoted by angiogenic factors and new capillaries. In 1883, Hulke reported successful trepanning of a patient with CSDH. Burr holes and craniotomy for removal of the hematoma were subsequently reported, and new methods were developed over the course of several decades around the world. In Japan, after the first report by Nakada in 1938, many Japanese pioneering figures of neurological surgery have studied CSDH. After Mandai reported the middle meningeal artery embolization in 2000, this method is now considered useful as an initial or second treatment for CSDH. However, the age of patients is increasing, so more minimally invasive surgeries and useful pharmacotherapies are needed. We must also consider the costs for treating CSDH, because of the increasing numbers of surgical cases.

Challenges and opportunities in the care of chronic subdural haematoma: perspectives from a multi-disciplinary working group on the need for change

INTRODUCTION

A chronic subdural haematoma (cSDH) is a collection of altered blood products between the dura and brain resulting in a slowly evolving neurological deficit. It is increasingly common and, in high income countries, affects an older, multimorbid population. With changing demographics improving the care of this cohort is of increasing importance.

METHODS

We convened a cross-disciplinary working group (the 'Improving Care in Elderly Neurosurgery Initiative') in October 2020. This comprised experts in neurosurgical care and a range of perioperative stakeholders. An Implementation Science framework was used to structure discussions around the challenges of cSDH care within the United Kingdom. The outcomes of these discussions were recorded and summarised, before being circulated to all attendees for comment and refinement.

RESULTS

The working group identified four key requirements for improving cSDH care: (1) data, audit, and natural history; (2) evidence-based guidelines and pathways; (3) shared decision-making; and (4) an overarching quality improvement strategy. Frequent transfers between care providers were identified as impacting on both perioperative care and presenting a barrier to effective data collection and teamworking. Improvement initiatives must be cognizant of the complex, system-wide nature of the problem, and may require a combination of targeted trials at points of clinical equipoise (such as anesthetic technique or anticoagulant management), evidence-based guideline development, and a cycle of knowledge acquisition and implementation.

CONCLUSION

The care of cSDH is a growing clinical problem. Lessons may be learned from the standardised pathways of care such as those as used in hip fracture and stroke. A defined care pathway for cSDH, encompassing perioperative care and rehabilitation, could plausibly improve patient outcomes but work remains to tailor such a pathway to cSDH care. The development of such a pathway at a national level should be a priority, and the focus of future work.

Peripheral blood eosinophil and classification of residual hematoma help predict the recurrence of chronic subdural hematoma after initial surgery

Chronic subdural hematoma (CSDH) is a common type of intracranial hemorrhage in neurosurgical practice, whose incidence has increased markedly in recent years. However, CSDH still troubles clinicians with a high postoperative recurrence rate. The presence of eosinophils has been confirmed in some CSDH surgical specimens. Furthermore, postoperative residual hematoma has not been classified, and its association with the recurrence of CSDH remains unknown. The present study aimed to test the hypothesis that the peripheral blood eosinophils and the classification of postoperative residual hematoma are significant for the prediction of CSDH recurrence after burr-hole surgery. A retrospective review of 258 CSDH patients who received burr-hole surgery was performed. A complete blood picture with differential count was taken before surgery. Clinical, laboratory, and radiographic factors predicting CSDH recurrence were identified in univariable and multivariable analyses. Univariable analysis showed that the percentage of eosinophils, peripheral blood eosinophil count <0.15 × 10⁹/L, gradation and separated types, postoperative volume of the residual cavity ≥70 ml, residual air volume ≥28 ml, residual hematoma volume ≥55 ml, residual hematoma width ≥1.4 cm, postoperative midline shift ≥5.6 mm, postoperative brain re-expansion rate <41%, postoperative low-density type, and postoperative high-density type correlated with the recurrence of CSDH. Multivariable analysis, however, showed that peripheral blood eosinophil count <0.15 × 10⁹/L, gradation and separated types, preoperative midline shift ≥9.5 mm, postoperative brain re-expansion rate <41%, postoperative low-density type, and postoperative high-density type are independent predictors for the recurrence of CSDH. We expect that peripheral blood eosinophils and the classification of postoperative residual hematoma may facilitate our understanding of the recurrence of CSDH after initial surgery.

In-hospital mortality rates, complication rates, length of stay, and total costs of >14,000 chronic subdural hematomas treated in the U.S. between 2016 and 2020: Query of the premier health-care database

Background:

With the drastically aging population in the U.S., chronic subdural hematomas (cSDHs) are projected to represent the most common neurosurgical diagnosis requiring treatment within the next two decades. There is lack of contemporary outcome data in patients treated for nontraumatic and nonacute subdural hematoma. We aim to portray current mortality rates, complication rates, length of stay, and costs associated with inpatient cSDH care.

Methods:

The Premier Health-care Database, Premier Inc., Charlotte/NC was queried for encounters October 2016–December 2020 with the ICD-10 diagnoses of nontraumatic nonacute subdural hematoma as the principal diagnosis among patients age ≥40 years. Per database in-hospital mortality is defined as mortality in an inpatient who is not discharged. Complications represent medical conditions not present on admission that affects mortality, length of stay, and costs within the database.

Results:

The query identified 14,136 inpatient encounters. Between October 2016 and December 2020, in-hospital mortality rates averaged 10.9% in the medical group (MG) and 3.6% in the surgical group (SG) (P < 0.001). Complication rates averaged between 8.9 % in the MG and 19.9% in the SG (P < 0.001). LOS averaged 3.0 days in the MG and 5.7 days in the SG (P < 0.001). Total costs averaged $ 10,233 in the MG and $ 26,658 in the SG.

Conclusion:

The standardized outcomes presented represent an objective benchmark of contemporary cSDH treatment outcomes in the U.S. With the projected substantial increase of cSDH cases within the next decades, new treatment strategies such as middle meningeal embolization need to be explored and outperform current outcome metrics.

Traumatic brain injury in the elderly after a skiing accident: A retrospective cohort study in a level 1 emergency department in Switzerland

Background

Skiing is a very popular sport worldwide, with increasing trends over the past decades. This study aimed to evaluate the importance of traumatic brain injury (TBI), especially in the elderly, after a ski accident, and to describe its short-term repercussions.

Methodology

Patients were analyzed who were admitted to our neurotrauma center from 2012–2018 after a head trauma while skiing. Three different age groups were differentiated and analyzed for the severity of TBI depending on the initial Glasgow Coma Scale as the primary outcome and as secondary outcomes need and type of surgery, Glasgow Outcome Score, preexisting use of anticoagulant or antiplatelet drugs, time to presentation, and pattern of brain injury. TBI severity was adjusted to the time to initial medical consultation.

Results

No significant difference in TBI severity was found when comparing the middle (>29–54) and older (≥54) age groups to the reference group <30 years (OR:0.45, p = 0.127; OR:0.46, p = 0.17). Acute subdural hemorrhage was present in 21.2% of the ≥55 group and 14.5% of the 30–54 age group, compared to 12.8% of the youngest group (p = <0.001). Overall, 39.4% of the patients in the ≥55 group and 8.1% of the 30–54 age group presented with chronic subdural hemorrhage, whereas none of the youngest patients did (p = <0.001).

Conclusion

No differences were observed in terms of TBI severity between age groups after acute trauma. Nonetheless, a different pattern of head injury after TBI in older patients was demonstrated. Accordingly, the management differs for these TBIs compared to those of younger patients.

Embolization of the Middle Meningeal Artery for the Treatment of Chronic Subdural Hematoma: A Path Less Travelled So Far

Introduction  Chronic subdural hematoma (CSDH) is relatively common and usually encountered in elderly population. With steady increase in life expectancy, incidence of CSDH also is bound to increase proportionately. Though surgery is the treatment of choice and relatively a simpler procedure, recurrence is a cause of concern. Embolization of the middle meningeal artery (MMA) is a newly evolving treatment modality in CSDH and offers hope in some of the recently published case series. Materials and Methods  Five cases of CSDH were subjected to embolization of MMA over a period from October 2019 to July 2020. Among them, it was employed for treatment in four cases after at least two recurrences following surgery, and in one case, it was done as the patient was not fit for surgery. All procedures were done under general anesthesia and polyvinyl alcohol (PVA) particles were used for embolization. Follow-up of the patients were done with computed tomography brain at 4 weeks and after 6 months of the procedure. Results  There was no incidence of recurrence in our series. Furthermore, embolization per se did not cause any complication or side effect which could be directly attributable to the procedure itself. Conclusion  In carefully selected patients based on clinical profile and angiographic findings, MMA embolization can be an effective modality for the treatment in CSDH.

A Single-Center Analysis of Sex Differences in Patients With Chronic Subdural Hematoma in China

Background

Given the men's predominance in the prevalence of chronic subdural hematoma (CSDH), we investigated the relationship between sex differences and clinical features of CSDH.

Methods

We retrieved a large collection of clinical factors from CSDH patients between August 2011 and May 2019, and analyzed the differences and similarities in the clinical data and outcomes between men and women.

Results

In total 1,307 CSDH patients were enrolled in this study. When we did not account for age, a greater proportion of women relative to men manifested diabetes (p = 0.001) and cardiac disease (p = 0.035) prior to the onset of CSDH. Regarding recovery outcome and recurrence rate, we observed no significant differences between men and women. The sole difference between women and men after surgery was that women experienced more complications than men (p = 0.044), and both length of hospital stay (p < 0.001, B = 0.159, Exp [B] = 1.172, 95% CI = 1.078–1.274) and the presence of cardiac disease (p = 0.002, B = 2.063, Exp [B] = 7.867, 95% CI = 2.167–28.550) were identified as independent risk factors. After accounting for age, women with CSDH exhibited more frequent disorders of consciousness at admission than men in group of ≤ 40-year-old patients (p = 0.018), while proportion of women with diabetes was higher than that of men in 41–79 year-old group (p < 0.001). However, women after surgery experienced more complications (p = 0.047), longer length of hospital stays (p = 0.005), and higher mortality at discharge (p = 0.035) than men in middle-aged group. Finally, length of hospital stay (p < 0.001, B = 0.186, Exp [B] = 1.205, 95% CI = 1.091–1.331) and cardiac disease (p = 0.017, B = 2.040, Exp [B] = 7.693, 95% CI = 1.430–41.372) impacted occurrence of complications in women 41–79-year-old, while duration of drainage catheter use (p < 0.001, B = 1.132, beta = 0.280) and complications (p < 0.001, B = 5.615, beta = 0.366) were identified as independent risk factors for length of hospital stay in the same group of women.

Conclusions

Although sex differences did not constitute a crucial factor in all the CSDH patients, we still need to pay closer attention to disparities between men and women with respect to complications, length of hospital stay, and mortality at discharge in the various age groups (particularly with respect to 41–79 year-old women patients), to provide satisfactory management and treatment of CSDH patients.

Puerto Rico Recurrence Scale: Predicting chronic subdural hematoma recurrence risk after initial surgical drainage

Background:

Chronic subdural hematoma (CSDH) commonly affects older individuals and is associated with a relatively high rate of recurrence after surgery. Many studies have created grading systems to identify patients at high risk of CSDH recurrence after the initial surgery. However, no system has been adopted widely. The authors present the first CSDH grading system created from a population-based single-center data set.

Methods:

A single-center Puerto Rican population-based retrospective analysis was performed on consecutive patients treated for a CSDH at a designated institution from July 1, 2017 to December 31, 2019. Univariate and multivariate analyses were used to create a CSDH recurrence grading scale. Retrospective validation was conducted on this sample population.

Results:

The study included 428 patients. Preoperative midline shift, postoperative midline shift, and size of postoperative subdural space differed between the recurrence and nonrecurrence groups (P = 0.03, 0.002, and 0.002, respectively). A multivariate analysis was used to create a 10-point grading scale comprising four independent variables. Recurrence rates progressively increased from the low-risk (0–3 points) to high-risk (8–10 points) groups (2.9% vs. 20.3%; P < 0.001).

Conclusion:

A 10-point grading scale for CSDH recurrence was developed with four components: preoperative midline shift (≤1 and >1 cm), laterality (bilateral, unilateral-right, and unilateral-left), size of postoperative subdural space (≤1.6 and >1.6 cm), and pneumocephalus (present or absent). Patients who scored higher on the scale had a higher risk of recurrence. This CSDH grading scale has implications for Puerto Rico and the general population as the elderly population increases worldwide.

Risk factors of recurrence in chronic subdural hematoma and a proposed extended classification of internal architecture as a predictor of recurrence

Chronic subdural hematomas (cSDHs) constitute one of the most prevalent intracranial disease entities requiring surgical treatment. Although mostly taking a benign course, recurrence after treatment is common and associated with additional morbidity and costs. Aim of this study was to develop hematoma-specific characteristics associated with risk of recurrence. All consecutive patients treated for cSDH in a single university hospital between 2015 and 2019 were retrospectively considered for inclusion. Size, volume, and midline shift were noted alongside relevant patient-specific factors. We applied an extended morphological classification system based on internal architecture in CT imaging consisting of eight hematoma subtypes. A logistic regression model was used to assess the classification’s performance on predicting hematoma recurrence. Recurrence was observed in 122 (32.0%) of 381 included patients. Apart from postoperative depressed brain volume (OR 1.005; 95% CI 1.000 to 1.010; p = 0.048), neither demographic nor factors related to patient comorbidity affected recurrence. The extended hematoma classification was identified as a significant predictor of recurrence (OR 1.518; 95% CI 1.275 to 1.808; p < 0.001). The highest recurrence rates were observed in hematomas of the homogenous (isodense: 41.4%; hypodense: 45.0%) and sedimented (50.0%) types. Our results support that internal architecture subtypes might represent stages in the natural history of chronic subdural hematoma. Detection and treatment at a later stage of spontaneous repair can result in a reduced risk of recurrence. Based on their high risk of recurrence, we advocate follow-up after treatment of sedimented and homogenous hematomas.