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Iaccarino C, Carretta A, Demetriades AK, Di Minno G, Giussani C, Marcucci R, Marklund N, Mastrojanni G, Pompucci A, Stefini R, Zona G, Cividini A, Petrella G, Coluccio V, Marietta M. Management of Antithrombotic Drugs in Patients with Isolated Traumatic Brain Injury: An Intersociety Consensus Document. Neurocrit Care 2024; 40:314-327. [PMID: 37029314 DOI: 10.1007/s12028-023-01715-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 03/07/2023] [Indexed: 04/09/2023]
Abstract
BACKGROUND All available recommendations about the management of antithrombotic therapies (ATs) in patients who experienced traumatic brain injury (TBI) are mainly based on expert opinion because of the lack of strength in the available evidence-based medicine. Currently, the withdrawal and the resumption of AT in these patients is empirical, widely variable, and based on the individual assessment of the attending physician. The main difficulty is to balance the thrombotic and hemorrhagic risks to improve patient outcome. METHODS Under the endorsement of the Neurotraumatology Section of Italian Society of Neurosurgery, the Italian Society for the Study about Haemostasis and Thrombosis, the Italian Society of Anaesthesia, Analgesia, Resuscitation, and Intensive Care, and the European Association of Neurosurgical Societies, a working group (WG) of clinicians completed two rounds of questionnaires, using the Delphi method, in a multidisciplinary setting. A table for thrombotic and bleeding risk, with a dichotomization in high risk and low risk, was established before questionnaire administration. In this table, the risk is calculated by matching different isolated TBI (iTBI) scenarios such as acute and chronic subdural hematomas, extradural hematoma, brain contusion (intracerebral hemorrhage), and traumatic subarachnoid hemorrhage with patients under active AT treatment. The registered indication could include AT primary prevention, cardiac valve prosthesis, vascular stents, venous thromboembolism, and atrial fibrillation. RESULTS The WG proposed a total of 28 statements encompassing the most common clinical scenarios about the withdrawal of antiplatelets, vitamin K antagonists, and direct oral anticoagulants in patients who experienced blunt iTBI. The WG voted on the grade of appropriateness of seven recommended interventions. Overall, the panel reached an agreement for 20 of 28 (71%) questions, deeming 11 of 28 (39%) as appropriate and 9 of 28 (32%) as inappropriate interventions. The appropriateness of intervention was rated as uncertain for 8 of 28 (28%) questions. CONCLUSIONS The initial establishment of a thrombotic and/or bleeding risk scoring system can provide a vital theoretical basis for the evaluation of effective management in individuals under AT who sustained an iTBI. The listed recommendations can be implemented into local protocols for a more homogeneous strategy. Validation using large cohorts of patients needs to be developed. This is the first part of a project to update the management of AT in patients with iTBI.
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Affiliation(s)
- Corrado Iaccarino
- Department of Biomedical, Metabolic and Neural Sciences, School of Neurosurgery, University of Modena and Reggio Emilia, Modena, Italy
- Neurosurgery Division, "Nocsae" Hospital of Baggiovara, University Hospital of Modena, Modena, Italy
- Emergency Neurosurgery Unit, AUSL RE IRCCS, "ASMN" Hospital of Reggio Emilia, Reggio Emilia, Italy
| | - Alessandro Carretta
- Department of Biomedical and Neuromotor Sciences (DIBINEM), University of Bologna, Bologna, Italy.
| | | | - Giovanni Di Minno
- Regional Reference Center for Coagulation Disorders, Federico II University Hospital, Naples, Italy
- Department of Clinical and Surgical Medicine, Federico II University of Naples, Naples, Italy
| | - Carlo Giussani
- Department of Neurosurgery, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Rossella Marcucci
- Center for Atherothrombotic Disease, Department of Experimental and Clinical Medicine, Careggi University Hospital, University of Florence, Florence, Italy
| | - Niklas Marklund
- Department of Neuroscience, Neurosurgery, Uppsala University, Uppsala, Sweden
- Department of Clinical Sciences, Department of Neurosurgery, Skåne University Hospital, Lund University, Lund, Sweden
| | | | - Angelo Pompucci
- Neurosurgery Division, ASL Latina Ospedale Santa Maria Goretti, Latina, Italy
| | - Roberto Stefini
- Neurosurgery Division, Department of Neurosciences, Head, Neck and Neurosurgery, Ospedale Civile di Legnano, Legnano, Italy
| | - Gianluigi Zona
- Neurosurgery Division, Department of Neurosciences (DINOGMI), IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Andrea Cividini
- Neurosurgery Division, Department of Neurosciences, Head, Neck and Neurosurgery, Ospedale Civile di Legnano, Legnano, Italy
| | - Gianpaolo Petrella
- Neurosurgery Division, ASL Latina Ospedale Santa Maria Goretti, Latina, Italy
| | - Valeria Coluccio
- Department of Hematology and Oncology, Hemostasis and Thrombosis Unit, University Hospital of Modena, Modena, Italy
| | - Marco Marietta
- Department of Hematology and Oncology, Hemostasis and Thrombosis Unit, University Hospital of Modena, Modena, Italy
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Wu L, Guo X, Ou Y, Yu X, Zhu B, Yang C, Liu W. Efficacy analysis of neuroendoscopy-assisted burr-hole evacuation for chronic subdural hematoma: a systematic review and meta-analysis. Neurosurg Rev 2023; 46:98. [PMID: 37115314 DOI: 10.1007/s10143-023-02007-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 03/13/2023] [Accepted: 04/23/2023] [Indexed: 04/29/2023]
Abstract
The purpose of this study was to compare neuroendoscopy-assisted burr-hole evacuation with conventional burr-hole evacuation in the treatment of chronic subdural hematoma (CSDH), and to evaluate the curative effect of neuroendoscopy. This study follows PRISMA guidelines and uses the keywords "chronic subdural hematoma," "neuroendoscopies," "neuroendoscopy," "endoscopy," "endoscopic neurosurgery," and "neuroendoscopic surgery" to conduct an electronic search of online databases, including PubMed, Embase, Web of Science, and Cochrane Library. There were no restrictions on language or publication year. This meta-analysis involved 948 patients in six studies. The results showed that the recurrence rate in the neuroendoscopy group was significantly lower than that in the conventional burr-hole group (3.1% vs. 13.8%, P<0.001). Compared with the control group, the neuroendoscopy group had a longer operation time (P<0.001) and a shorter postoperative drainage time (P<0.001). In addition, there was no significant difference in hospital stay (P=0.14), mortality (P=0.39), postoperative morbidity (P=0.12), or 6-month neurological outcomes (P=0.32) between the two groups. It should be noted that the comparison of neurological outcomes was based on 269 patients (6/106 vs. 14/163). Compared with conventional burr-hole evacuation, neuroendoscopy-assisted burr-hole evacuation reduces the recurrence rate of CSDH and shortens the postoperative drainage time. However, the neuroendoscopy group did not have lower mortality or morbidity or better functional outcomes. In the future, randomized controlled trials are needed to further evaluate the efficacy and safety of neuroendoscopic surgery.
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Affiliation(s)
- Liang Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xufei Guo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yunwei Ou
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, Beihang University, Beijing, China
| | - Xiaofan Yu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Bingcheng Zhu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Cheng Yang
- The Third Clinical Medical College, Ningxia Medical University, Yinchuan, China
| | - Weiming Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
- China National Clinical Research Center for Neurological Diseases, Beijing, China.
- Neurological Center, People's Hospital of Ningxia Hui Autonomous Region (The Third Clinical Medical College, Ningxia Medical University), Yinchuan, China.
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Kwon SM, Lee MH, Seo Y, Kim YI, Oh HJ, Kim KH, Choi KS, Chong K. A Radiological Assessment of Chronic Subdural Hematomas. Korean J Neurotrauma 2022; 18:12-21. [PMID: 35557646 PMCID: PMC9064761 DOI: 10.13004/kjnt.2022.18.e24] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 04/15/2022] [Accepted: 04/17/2022] [Indexed: 11/15/2022] Open
Abstract
Chronic subdural hematoma (CSDH), which generally occurs in elderly patients, is a frequently diagnosed condition in neurosurgical departments. Computed tomography (CT) and magnetic resonance imaging (MRI) are the most preferred diagnostic modalities for CSDH assessment. With early diagnosis and adequate management, CSDH may show favorable prognosis in majority of the patients; however, recurrence after surgery can occur in a significant number of patients. The recently increasing number of CSDH studies could reveal the prognostic factors affecting CSDH recurrence. Particularly, radiological characteristics regarding the internal architecture of CSDH are considered closely associated with recurrence in surgically treated CSDH patients. In this literature review, we evaluated the various diagnostic modalities of CSDH and its radiological characteristics on CT and MRI. Furthermore, we summarized the prognostic factors of recurrence for the hematoma type based on the radiological findings.
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Affiliation(s)
- Sae Min Kwon
- Neurotrauma Clinical Practice Guidelines Committee of the Korean Neurotraumatology Society (KNTS-NCPGC), Seoul, Korea
- Department of Neurosurgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Min Ho Lee
- Neurotrauma Clinical Practice Guidelines Committee of the Korean Neurotraumatology Society (KNTS-NCPGC), Seoul, Korea
- Department of Neurosurgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Youngbeom Seo
- Neurotrauma Clinical Practice Guidelines Committee of the Korean Neurotraumatology Society (KNTS-NCPGC), Seoul, Korea
- Department of Neurosurgery, Yeungnam University Hospital, Yeungnam Universtiy College of Medicine, Daegu, Korea
| | - Young Il Kim
- Neurotrauma Clinical Practice Guidelines Committee of the Korean Neurotraumatology Society (KNTS-NCPGC), Seoul, Korea
- Department of Neurosurgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyuk-Jin Oh
- Neurotrauma Clinical Practice Guidelines Committee of the Korean Neurotraumatology Society (KNTS-NCPGC), Seoul, Korea
- Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Kyung Hwan Kim
- Neurotrauma Clinical Practice Guidelines Committee of the Korean Neurotraumatology Society (KNTS-NCPGC), Seoul, Korea
- Department of Neurosurgery, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Kyu-Sun Choi
- Neurotrauma Clinical Practice Guidelines Committee of the Korean Neurotraumatology Society (KNTS-NCPGC), Seoul, Korea
- Department of Neurosurgery, Hanyang University Medical Center, Hanyang University College of Medicine, Seoul, Korea
| | - Kyuha Chong
- Neurotrauma Clinical Practice Guidelines Committee of the Korean Neurotraumatology Society (KNTS-NCPGC), Seoul, Korea
- Department of Neurosurgery, Brain Tumor Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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De Jesus O, Monserrate AE. Burr Hole Surgery for Drainage of Chronic and Subacute Subdural Hematomas: Low Recurrence Rate in a Single Surgeon Cohort. Cureus 2021; 13:e19288. [PMID: 34900470 PMCID: PMC8648283 DOI: 10.7759/cureus.19288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2021] [Indexed: 11/17/2022] Open
Abstract
Background: A complication after surgical intervention for chronic and subacute subdural hematoma drainage is the recurrence of hematoma, often requiring repeat surgical management. Recurrence rates varied widely across the published series, which may partially be due to different technical strategies used by the surgeons involved in the study. We decided to review our patients with chronic and subacute subdural hematomas that were surgically managed with a burr hole procedure by a single surgeon to compare recurrence rates with the evidence available. Methods: A retrospective review of the medical records was performed on the patients who underwent burr hole surgical intervention to drain a chronic or subacute subdural hematoma between April 1995 and March 2020. All patients were under the care of a single surgeon at an academic institution. Variables analyzed included age, sex, laterality of the hematoma, and recurrence. Results: During the selected timeframe, 610 cases were identified. There were 35 cases of recurrence of the hematoma. The recurrence rate after burr hole drainage was 5.73%. Conclusion: Surgical drainage of chronic and subacute subdural hematoma via burr hole using consistent stepwise management is associated with a relatively low recurrence rate in our single surgeon patient cohort.
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Affiliation(s)
- Orlando De Jesus
- Neurosurgery, University of Puerto Rico, Medical Sciences Campus, San Juan, PRI
| | - Andres E Monserrate
- Neurosurgery, University of Puerto Rico, Medical Sciences Campus, San Juan, PRI
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Erdogan B, Is M, Tural Emon S, Ceman D, Orakdogen M, Engin T. Retrospective analysis of 195 surgically treated cases of chronic subdural hematoma. Int J Clin Pract 2021; 75:e15014. [PMID: 34808025 DOI: 10.1111/ijcp.15014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 04/17/2021] [Accepted: 11/19/2021] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION The incidence of chronic subdural hematoma (CSDH) is increasing. This study evaluates the etiologic causes and findings of CSDH and compared unilateral CSDH with bilateral CSDH. This study aims to draw attention to this increasingly prevalent condition. METHODS We retrospectively analysed 195 surgically treated cases of CSDH in our clinic between 2008 and 2018. RESULTS The average age of the patients was 65.7 ± 19.6 years. The most common symptom was headache (53.3%). The case background was the use of anticoagulant (37.9%), head trauma (34.3%). The hematomas were 28.7% right side, 44.6% left side, and 26.7% bilateral. The mean Glasgow Coma Score (GCS) was 13.4 ± 2.9, early postop 13.8 ± 2.5, and late postop was 14.6 ± 1.1. Postoperative complications included acute subdural hematoma (5.1%), cerebral infarction (1.5%), wound infection (0.5%) and others (13.3%). Re-expansion of the brain were statistically significantly less frequent and impaired consciousness, anticoagulant use, early and late postop thickness were statistically significantly more frequent in patients with bilateral CSDH. CONCLUSIONS CSDH is seen more patients of advanced age, those who use anticoagulants, patients with hypertension and diabetes and in patients with a history of head trauma. Prognosis is worse in bilateral CSDH. We estimate that the incidence of CSDH will go up in the future.
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Affiliation(s)
- Baris Erdogan
- Department of Neurosurgery, Sanliurfa Training and Research Hospital, Şanlıurfa, Turkey
| | - Merih Is
- Department of Neurosurgery, University of Health Sciences Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | - Selin Tural Emon
- Department of Neurosurgery, University of Health Sciences Haydarpaşa Numune Training and Research Hospital, Istanbul, Turkey
| | - Duygu Ceman
- Department of Neurosurgery, Sancaktepe Şehit Prof. Dr. İlhan Varank Training and Research Hospital, Istanbul, Turkey
| | - Metin Orakdogen
- Department of Neurosurgery, University of Trakya, Edirne, Turkey
| | - Taner Engin
- Department of Neurosurgery, University of Health Sciences Mehmet Akif İnan Training and Research Hospital, Istanbul, Turkey
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Tamura R, Sato M, Yoshida K, Toda M. History and current progress of chronic subdural hematoma. J Neurol Sci 2021; 429:118066. [PMID: 34488045 DOI: 10.1016/j.jns.2021.118066] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Revised: 08/25/2021] [Accepted: 08/31/2021] [Indexed: 11/18/2022]
Abstract
Chronic subdural hematoma (CSDH) is characterized by an encapsulated collection of old blood. Although CSDH has become the most frequent pathologic entity in daily neurosurgical practice, there are some unresolved research questions. In particular, the causes and recurrent risk factors of CSDH remain as an object of debate. The split of the dural border layer forms a few tiers of dural border cells over the arachnoid layer. Tissue plasminogen activator plays an important role as a key factor of defective coagulation. Historically, CSDH has often been treated via burr hole craniostomy using a closed drainage system. Several different operative strategies and peri-operative strategies such as the addition of burr holes, addition of cavity irrigation, position of drain, or postural position, have been described previously. Although the direction of the drainage tube, residual air, low intensity of T1-weighted images on MRI, and niveau formation have been reported as risk factors for recurrence, antiplatelet or anticoagulant drug use has not yet been verified as a risk factor. Recently, pharmaceutical strategies, including atorvastatin, significantly improved the neurological function in CSDH patients. Many case series, without randomization, have been reported; and given its promising result, several randomized clinical trials using pharmaceutical as well as operative and perioperative strategies were initiated to obtain sufficient data. In contrast, relatively fewer basic studies have achieved clinical applications in CSDH, although it is one of the most common clinical entities. Further scientific basic research may be essential for achieving a novel treatment strategy for CSDH.
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Affiliation(s)
- Ryota Tamura
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan; Department of Neurosurgery, Kawasaki Municipal Hospital, Shinkawadori, Kawasaki-ku, Kanagawa 210-0013, Japan
| | - Mizuto Sato
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Kazunari Yoshida
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan
| | - Masahiro Toda
- Department of Neurosurgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan.
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Pathoumthong K, Jetjumnong C. Comparative study of subdural drain (SDD) versus sub periosteal drain (SPD) in treating patient with chronic subdural hematoma (CSDH). Surg Neurol Int 2021; 12:421. [PMID: 34513185 PMCID: PMC8422541 DOI: 10.25259/sni_592_2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 07/30/2021] [Indexed: 11/06/2022] Open
Abstract
Background: Chronic subdural hematoma (CSDH) is common neurosurgical condition encountered in daily practice. Burr holes evacuation is standard treatment for symptomatic cases. Both subdural drain (SDD) and subperiosteal drain (SPD) have been reported to lower the recurrence rate when used in conjunction with burr holes. A randomized controlled trials were done to see if there were any differences in clinical and radiographic outcomes between the two types of drains. Methods: A total of 42 CSDH patients were enrolled and allocated to one of two groups: SDD (n = 21) or SPD (n = 21). Demographic data, perioperative imaging characteristics, clinical outcome, and recurrence rate were recorded for comparison. Results: In both groups, demographic characteristics such as sex ratio, mean age of patients, concomitant disease, and antithrombotic agent use were similar. At 6 months, 20 (95.2%) and 21 (100%) cases in the SDD and SPD groups, respectively, had a favorable outcome (mRS 0–3). Complete hematoma resolution at 6 months was achieved in 21 (100%) and 19 (90.5%) cases of the SDD and SPD groups, respectively. The amount of drain within 48 h was not difference between the two groups. None of the SDD recurred, but two of the SPD group did, necessitating reoperation, which had no effect on the final outcome. Conclusion: These findings indicate that the drain type (SDD or SPD) has no effect on the outcome. The surgeon’s preference determines which procedure is used. Except in symptomatic circumstances, routine postoperative imaging may not be required.
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Affiliation(s)
- Kolakoth Pathoumthong
- Department of Surgery, Division of Neurosurgery, Chiang Mai University, Chiang Mai, Thailand
| | - Chumpon Jetjumnong
- Department of Surgery, Division of Neurosurgery, Chiang Mai University, Chiang Mai, Thailand
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Oda K, Aso S, Hattori Y, Yamaguchi F, Matsui H, Fushimi K, Yasunaga H, Morita A. Snowfall reduces the risk of chronic subdural hematoma onset: Analysis of an administrative database in Japan. Surg Neurol Int 2021; 12:69. [PMID: 33767873 PMCID: PMC7982109 DOI: 10.25259/sni_882_2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 01/26/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Chronic subdural hematoma (CSDH) is a frequently observed disease in neurosurgical practice. Although first snowfall has been considered to increase the onset of CSDH, few reports have assessed the relationship between snowfall and CSDH. In this study, we aimed to investigate the relationship between CSDH onset and first snowfall events. Methods: This retrospective study was based on the Japanese Diagnosis Procedure Combination inpatient database from July 1, 2010, to March 31, 2016, and on the global observation of snowfall events in Japan obtained from the Japan Meteorological Agency. We used a binomial approximation to evaluate the average number of CSDH patients after first snowfall events compared with that before first snowfall events. We calculated the odds ratio of CSDH onset on the first snowfall. Results: We identified 8526 CSDH patients from the database. A total of 5573 (65.4%) were observed before first snowfall events, and 2953 (34.6%) after first snowfall events. The first snowfall of winter was significantly associated with a reduction in the occurrence of CSDH (odds ratio, 0.53; 95% confidence interval; 0.51–0.55). In subgroup analysis, only the first snowfall in October was not associated with reduction in the occurrence of CSDH. Conclusion: First snowfall events did not affect the onset of CSDH in Japan.
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Affiliation(s)
- Kazunori Oda
- Department of Neurological Surgery, Nippon Medical School, Bunkyo-ku, Japan
| | - Shotaro Aso
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Japan
| | - Yujiro Hattori
- Department of Neurological Surgery, Nippon Medical School, Bunkyo-ku, Japan.,Department of Anatomy and Neurobiology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Fumio Yamaguchi
- Department of Neurological Surgery, Nippon Medical School, Bunkyo-ku, Japan.,Department of Neurosurgery for Community Health, Nippon Medical School, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Japan
| | - Akio Morita
- Department of Neurological Surgery, Nippon Medical School, Bunkyo-ku, Japan
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Critical Depressed Brain Volume Influences the Recurrence of Chronic Subdural Hematoma after Surgical Evacuation. Sci Rep 2020; 10:1145. [PMID: 31980723 PMCID: PMC6981211 DOI: 10.1038/s41598-020-58250-w] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 01/13/2020] [Indexed: 11/25/2022] Open
Abstract
Recurrence of chronic subdural hematoma (CSDH) frequently occurs after surgical evacuation. However, the value of follow-up postoperative imaging and measuring volumetric factors to predict recurrence are still controversial. Herein, we aimed to assess the optimal timing for follow-up referential imaging and the critical depressed brain volume for CSDH recurrence. A total of 291 patients with CSDH who underwent burr hole craniotomy between January 2012 and December 2018 were consecutively enrolled in this study. Patients’ medical records and radiologic data were evaluated to predict the recurrence and analyzed using receiver operating characteristics (ROC) and binary logistic regression. Of the 291 patients, 29 (10.0%) showed recurrence after surgical evacuation. Based on ROC analysis, comparisons of depressed brain volume pre-operation, 24 h post-operation, and 7 days post-operation showed that the depressed brain volume at 7 days after surgery featured the largest area under the curve (AUC: 0.768, 95% CI, 0.709–0.811). The cut-off value of the depressed brain volume on postoperative day 7 was 51.6 cm3; this value predicted the recurrence of CSDH with a sensitivity and specificity of 79.3% and 67.9%, respectively. In the multivariate analysis, the depressed brain volume (>50 cm3) at 7 days was the sole significant risk factor related to the recurrence of CSDH in this series (OR: 6.765, 95% CI, 2.551–17.942, p < 0.001). The depressed brain volume > 50 cm3 visualized on CT scans at postoperative 7 day is the critical volume affecting recurrence of CSDHs. This result could be helpful carrying in patients with CSDH to determine the proper postoperative treatment strategy.
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Kung WM, Lin MS. CT-Based Quantitative Analysis for Pathological Features Associated With Postoperative Recurrence and Potential Application Upon Artificial Intelligence: A Narrative Review With a Focus on Chronic Subdural Hematomas. Mol Imaging 2020; 19:1536012120914773. [PMID: 32238025 PMCID: PMC7290264 DOI: 10.1177/1536012120914773] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 10/23/2019] [Accepted: 02/14/2020] [Indexed: 02/05/2023] Open
Abstract
Chronic subdural hematomas (CSDHs) frequently affect the elderly population. The postoperative recurrence rate of CSDHs is high, ranging from 3% to 20%. Both qualitative and quantitative analyses have been explored to investigate the mechanisms underlying postoperative recurrence. We surveyed the pathophysiology of CSDHs and analyzed the relative factors influencing postoperative recurrence. Here, we summarize various qualitative methods documented in the literature and present our unique computer-assisted quantitative method, published previously, to assess postoperative recurrence. Imaging features of CSDHs, based on qualitative analysis related to postoperative high recurrence rate, such as abundant vascularity, neomembrane formation, and patent subdural space, could be clearly observed using the proposed quantitative analysis methods in terms of mean hematoma density, brain re-expansion rate, hematoma volume, average distance of subdural space, and brain shifting. Finally, artificial intelligence (AI) device types and applications in current health care are briefly outlined. We conclude that the potential applications of AI techniques can be integrated to the proposed quantitative analysis method to accomplish speedy execution and accurate prediction for postoperative outcomes in the management of CSDHs.
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Affiliation(s)
- Woon-Man Kung
- Division of Neurosurgery, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Muh-Shi Lin
- Division of Neurosurgery, Department of Surgery, Kuang Tien General Hospital, Taichung, Taiwan
- Department of Biotechnology and Animal Science, College of Bioresources, National Ilan University, Yilan, Taiwan
- Department of Biotechnology, College of Medical and Health Care, Hung Kuang University, Taichung, Taiwan
- Department of Health Business Administration, College of Medical and Health Care, Hung Kuang University, Taichung, Taiwan
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Holl DC, Volovici V, Dirven CMF, van Kooten F, Miah IP, Jellema K, Peul WC, van der Gaag NA, Kho KH, den Hertog HM, Dammers R, Lingsma HF. Corticosteroid treatment compared with surgery in chronic subdural hematoma: a systematic review and meta-analysis. Acta Neurochir (Wien) 2019; 161:1231-1242. [PMID: 30972566 DOI: 10.1007/s00701-019-03881-w] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 03/20/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND There is an ongoing debate on the role of corticosteroids in the treatment of chronic subdural hematoma (CSDH). This study aims to evaluate the effectiveness of corticosteroids for the treatment of CSDH compared to surgery. METHOD A systematic search was performed in relevant databases up to January 2019 to identify RCTs or observational studies that compared at least two of three treatment modalities: the use of corticosteroids as a monotherapy (C), corticosteroids as an adjunct to surgery (CS), and surgery alone (S). Outcome measures were good neurological outcome, need for reintervention, mortality, and complications. Effect estimates were pooled and presented as relative risk (RR) with 95% confidence interval (95%CI). RESULTS Of 796 initially identified studies, 7 were included in the meta-analysis. Risk of bias was generally high. There were no differences in good neurological outcome between treatment modalities. The need for reintervention varied between 4 and 58% in C, 4-12% in CS, and 7-26% in S. The need for reintervention was lower in CS compared with C (RR 3.34 [95% CI 1.53-7.29]; p < 0.01) and lower in CS compared with S (RR 0.44 [95% CI 0.27-0.72]; p < 0.01). Mortality varied between 0 and 4% in C, 0-13% in CS, and 0-44% in S. Mortality was lower in CS compared with S (RR 0.39 [95% CI 0.25-0.63]; p < 0.01). There were no differences in complications between treatment modalities. CONCLUSIONS This meta-analysis suggests that the addition of corticosteroids to surgery might be effective in the treatment of CSDH. However, the results must be interpreted with caution in light of the serious risk of bias of the included studies. This study stresses the need for large randomized trials to investigate the use of corticosteroids in the management of CSDH.
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Affiliation(s)
- Dana C Holl
- Department of Neurosurgery, Erasmus MC Stroke Centre, Erasmus Medical Centre, 2040, 3000 CA Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands.
| | - Victor Volovici
- Department of Neurosurgery, Erasmus MC Stroke Centre, Erasmus Medical Centre, 2040, 3000 CA Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
- Department of Public Health and Medical Decision Making, Erasmus MC, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Clemens M F Dirven
- Department of Neurosurgery, Erasmus MC Stroke Centre, Erasmus Medical Centre, 2040, 3000 CA Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Fop van Kooten
- Department of Neurology, Erasmus MC Stroke Centre, Erasmus Medical Centre, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Ishita P Miah
- Department of Neurology, Haaglanden Medical Centre, Postbus 432, 2501 CK, The Hague, The Netherlands
| | - Korné Jellema
- Department of Neurology, Haaglanden Medical Centre, Postbus 432, 2501 CK, The Hague, The Netherlands
| | - Wilco C Peul
- Department of Neurosurgery, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Niels A van der Gaag
- Department of Neurosurgery, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Haaglanden MC and Haga Teaching Hospital, Postbus 432, 2501 CK, The Hague, The Netherlands
| | - Kuan H Kho
- Department of Neurosurgery, Medisch Spectrum Twente, Koningsplein 1, 7512 KZ, Enschede, The Netherlands
| | - Heleen M den Hertog
- Department of Neurology, Isala Hospital Zwolle, Dokter van Heesweg 2, 8025 AB, Zwolle, The Netherlands
| | - Ruben Dammers
- Department of Neurosurgery, Erasmus MC Stroke Centre, Erasmus Medical Centre, 2040, 3000 CA Rotterdam, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
| | - Hester F Lingsma
- Department of Public Health and Medical Decision Making, Erasmus MC, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands
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12
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El Asri AC, Benzagmout M, Chakour K, Chaoui MF, Laaguili J, Gazzaz M, Baallal H, El Mostarchid B. Variation of Ventricular Size after Surgical Treatment of Chronic Subdural Hematoma. Asian J Neurosurg 2019; 14:122-125. [PMID: 30937022 PMCID: PMC6417319 DOI: 10.4103/ajns.ajns_298_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Surgical removal is the treatment of choice for chronic subdural hematoma (CSDH). Despite clinical improvement after surgery, computed tomography (CT) scan control often showed residual collection, which may discuss the possibility of failed surgery. The aim of this study is the assessment of ventricular size before and after surgery and to study its relation with residual hematoma. Methods In this prospective study (2013-2016), 63 patients who had burr-hole drainage of CSDH were sequentially allocated to either two groups; Group 1 with CT scan control under the 3rd day of surgery and Group 2 with delayed CT scan control (from 4th to 7th day). Linear measure of ventricular size was assessed by Evans' index. We reviewed and analyzed the data between both groups. Results There were 33 patients in Group 1 and 30 patients in Group 2. Preoperatively, the average thickness of hematoma was 20.5 mm in Group 1 versus 19.9 mm in Group 2 (P = 0.67); the mean midline shift was 8.5 mm in each group; Evans' index was 26.7% in Group 1 and 27% in Group 2 (P = 0.7). Postoperatively, the mean thickness of the residual hematoma was 7.7 mm in Group 1 and 8.4 mm in Group 2 (P = 0.57); the mean midline shift was 3.3 mm in Group 1 and 1.9 mm in Group 2 (P = 0.08); Evan's index was 28.5% in Group 1 and 32.1% in Group 2 (P = 0.002). Conclusion The adoption of Evans' index, for assessing the variation of ventricular size after surgery, by neurosurgeons appears to be a good and simple method for evaluation and following the success of surgical removal of CSDH, despite the observation of some residual collection in early CT scan control.
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Affiliation(s)
- Abad Cherif El Asri
- Department of Neurosurgery, Military Hospital, Rabat, Morocco.,Department of Neurosurgery, University Hospital Hassan II, Fes, Morocco
| | | | - Khalid Chakour
- Department of Neurosurgery, University Hospital Hassan II, Fes, Morocco
| | | | - Jawad Laaguili
- Department of Neurosurgery, Military Hospital, Rabat, Morocco
| | - Miloudi Gazzaz
- Department of Neurosurgery, Military Hospital, Rabat, Morocco
| | - Hassan Baallal
- Department of Neurosurgery, Military Hospital, Rabat, Morocco
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13
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Weng W, Li H, Zhao X, Yang C, Wang S, Hui J, Mao Q, Gao G, Feng J. The depth of catheter in chronic subdural haematoma: does it matter? Brain Inj 2018; 33:717-722. [PMID: 30325214 DOI: 10.1080/02699052.2018.1531312] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Objective: To investigate the appropriate depth of drainage catheter in the patients with chronic subdural haematoma (CSDH). Methods: We retrospectively analysed the data of 190 patients with CSDH undergoing single parietal burr-hole evacuation and drainage. Results: According to the depth of catheter (DC), 190 patients were divided into three groups: shallow group (DC <4.3 cm), middle group (DC 4.3 ~ 5.4 cm) and deep group (DC > 5.4 cm). During postdischarge 6 months, two, six and nine patients had recurrences in shallow, middle and deep groups, respectively. The recurrence rate in shallow or middle group was significantly lower than that in deep group. No significant difference in preoperative haematoma volume (PHV) was observed in three groups. While the residual subdural space (RSS) in shallow group was significantly smaller than those in the other two groups. The duration of drainage in shallow, middle and deep groups increased successively, and the differences were statistically significant. The total drainage volume (TDV) in shallow group showed no significant difference when compared with the other two groups. Conclusion: The depth of catheter may affect the outcome of CSDH. Inserting drainage catheter shallowly might be a preferred choice in patients with CSDH undergoing burr-hole evacuation and drainage.
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Affiliation(s)
- Weiji Weng
- a Department of Biochemistry and Molecular Cell Biology, Shanghai Key Laboratory for Tumor Microenvironment and Inflammation, Institute of Medical Sciences, School of Medicine , Shanghai Jiao Tong University , Shanghai People's Republic of China.,b Department of Neurosurgery, Renji Hospital, School of Medicine , Shanghai Jiao Tong University , Shanghai People's Republic of China.,c Shanghai Institute of Head Trauma , Shanghai People's Republic of China
| | - Hongpeng Li
- d Department of Neurosurgery , Ri Zhao Hospital of Traditional Chinese Medicine , Rizhao Shandong , People's Republic of China
| | - Xiaochun Zhao
- e Department of Neurosurgery, Barrow Neurological Institute , St. Joseph's Hospital and Medical Center , Phoenix AZ , USA
| | - Chun Yang
- b Department of Neurosurgery, Renji Hospital, School of Medicine , Shanghai Jiao Tong University , Shanghai People's Republic of China
| | - Shen Wang
- b Department of Neurosurgery, Renji Hospital, School of Medicine , Shanghai Jiao Tong University , Shanghai People's Republic of China
| | - Jiyuan Hui
- b Department of Neurosurgery, Renji Hospital, School of Medicine , Shanghai Jiao Tong University , Shanghai People's Republic of China
| | - Qing Mao
- b Department of Neurosurgery, Renji Hospital, School of Medicine , Shanghai Jiao Tong University , Shanghai People's Republic of China
| | - Guoyi Gao
- b Department of Neurosurgery, Renji Hospital, School of Medicine , Shanghai Jiao Tong University , Shanghai People's Republic of China.,c Shanghai Institute of Head Trauma , Shanghai People's Republic of China
| | - Junfeng Feng
- b Department of Neurosurgery, Renji Hospital, School of Medicine , Shanghai Jiao Tong University , Shanghai People's Republic of China.,c Shanghai Institute of Head Trauma , Shanghai People's Republic of China
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Tomita Y, Yamada SM, Yamada S, Matsuno A. Subdural Tension on the Brain in Patients with Chronic Subdural Hematoma Is Related to Hemiparesis but Not to Headache or Recurrence. World Neurosurg 2018; 119:e518-e526. [PMID: 30075268 DOI: 10.1016/j.wneu.2018.07.192] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Revised: 07/21/2018] [Accepted: 07/23/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Hemiparesis is a major symptom of chronic subdural hematoma (CSDH). Its severity does not always correlate with hematoma size. The authors analyzed hematoma thickness, pressure, and tension to clarify the mechanism of hemiparesis in CSDH patients. METHODS A burr-hole surgery was performed on 124 CSDHs in 102 patients. Hematoma thickness and midline shift were measured by computed tomography, and hematoma pressure was measured in surgery. According to Laplace law, tension was calculated as follows: (half the hematoma thickness × hematoma pressure)/2. Student t test and Pearson correlation coefficient (r) were applied in statistical analysis of findings. RESULTS Motor weakness was identified in 76.5% of our cases. Tension was strongly related to hemiparesis (r = -0.747, P < 0.01), whereas hematoma thickness (r = -0.458, P < 0.01) and pressure (r = -0.596, P < 0.01) were moderately correlated. Mean age of 14 patients (13.7%) with headache was much younger than those without headache (P < 0.01). Stronger midline shift (P < 0.01) and greater ratio of midline shift to hematoma thickness (P < 0.01) were statistically correlated with headache. Recurrence was recognized in 8 patients (7.8%), and stronger midline shift (P < 0.05) and greater ratio of midline shift to hematoma thickness (P < 0.05) were statistically associated with recurrence. CONCLUSIONS Tension is the most influencing factor to hemiparesis in CSDH patients. This study also elucidates the mechanism for quick recovery from hemiparesis after surgery in that tension on the motor cortex is decreased immediately by drainage.
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Affiliation(s)
- Yusuke Tomita
- Department of Neurosurgery, Teikyo University Hospital Mizonokuchi, Takatsu-ku, Kawasaki, Kanagawa, Japan
| | - Shoko Merrit Yamada
- Department of Neurosurgery, Teikyo University Hospital Mizonokuchi, Takatsu-ku, Kawasaki, Kanagawa, Japan.
| | - Shokei Yamada
- Department of Neurosurgery, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Akira Matsuno
- Department of Neurosurgery, Teikyo University Medical School, Itabashi-ku, Tokyo, Japan
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15
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Fomchenko EI, Gilmore EJ, Matouk CC, Gerrard JL, Sheth KN. Management of Subdural Hematomas: Part II. Surgical Management of Subdural Hematomas. Curr Treat Options Neurol 2018; 20:34. [PMID: 30019165 DOI: 10.1007/s11940-018-0518-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Management of patients with subdural hematomas starts with Emergency Neurological Life Support guidelines. Patients with acute or chronic subdural hematomas (SDHs) associated with rapidly deteriorating neurologic exam, unilaterally or bilaterally dilated nonreactive pupils, and extensor posturing are considered imminently surgical; likewise, SDHs more than 10 mm in size or those associated with more than 5-mm midline shift are deemed operative. RECENT FINDINGS While twist drill craniostomy and placement of subdural evacuating vport system (SEPS) are quick, bedside procedures completed under local anesthesia and appropriate for patients with chronic SDH or patients that cannot tolerate anesthesia, these techniques are not optimal for patients with acute SDH or chronic SDH with septations. Burr hole SDH evacuation under conscious sedation or general anesthesia is an analogous technique; however, it requires basic surgical equipment and operating room staff, with a focus on a closed system with burr hole followed by rapid drain placement to avoid introduction of air into the subdural space, or multiple burr holes with extensive irrigation to reduce pneumocephalus and continue SDH evacuation via drain for several days. Acute SDH associated with significant mass effect and cerebral edema requires aggressive decompression via craniotomy with clot evacuation and frequently a craniectomy. Chronic SDHs that fail conservative management and progress clinically or radiographically are addressed with craniotomy with or without membranectomy. Surgical SDH management is variable depending on its characteristics and etiology, patient's functional status, comorbidities, goals of care, institutional preferences, and availability of specialized surgical equipment and adjunct therapies. Rapid access to surgical suites and trained staff to address surgical hemorrhages in a timely manner, with appropriate post-operative care by a specialized team including neurosurgeons and neurointensivists, is of paramount importance for successful patient outcomes. Here, we review various aspects of surgical SDH management.
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Affiliation(s)
- Elena I Fomchenko
- Department of Neurosurgery, Yale University, 20 York St, New Haven, CT, USA.
| | - Emily J Gilmore
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
- Division of Neuro-Critical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Charles C Matouk
- Department of Neurosurgery, Yale University, 20 York St, New Haven, CT, USA
| | - Jason L Gerrard
- Department of Neurosurgery, Yale University, 20 York St, New Haven, CT, USA
| | - Kevin N Sheth
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
- Division of Neuro-Critical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
- Department of Clinical Neurosciences, Yale University, 20 York St, New Haven, CT, USA
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16
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Doan NB, Patel M, Nguyen HS, Doan H, Montoure A, Shabani S, Gelsomino M, Janich K. Safe Use of Tissue Plasminogen Activator in Conjunction with the Integra Camino Bolt for the Drainage of Chronic Subdural Hematoma. Asian J Neurosurg 2018; 13:485-486. [PMID: 29682068 PMCID: PMC5898139 DOI: 10.4103/ajns.ajns_230_16] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Chronic subdural hematoma (CSDH) is a relatively common condition encountered in a neurosurgical practice. There have been increased efforts in creating different treatment regimens for CSDH to improve patients' outcomes, including the addition of tissue plasminogen activator (tPA) in drains to reduce recurrences. Here, we present the first case report of the safe use of tPA in conjunction with an Integra Camino bolt for maximized drainage of CSDH with a successful neurological recovery and the complete resolution of the hematoma.
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Affiliation(s)
- Ninh B Doan
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Mohit Patel
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Ha Son Nguyen
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Hayley Doan
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Andrew Montoure
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Saman Shabani
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Michael Gelsomino
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Karl Janich
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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17
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Lee SH, Choi JI, Lim DJ, Ha SK, Kim SD, Kim SH. The Potential of Diffusion-Weighted Magnetic Resonance Imaging for Predicting the Outcomes of Chronic Subdural Hematomas. J Korean Neurosurg Soc 2017; 61:97-104. [PMID: 29354241 PMCID: PMC5769846 DOI: 10.3340/jkns.2016.0606.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 12/01/2016] [Accepted: 03/03/2017] [Indexed: 11/27/2022] Open
Abstract
Objective Diffusion-weighted magnetic resonance imaging (DW-MRI) has proven useful in the study of the natural history of ischemic stroke. However, the potential of DW-MRI for the evaluation of chronic subdural hematoma (CSDH) has not been established. In this study, we investigated DW-MRI findings of CSDH and evaluated the impact of the image findings on postoperative outcomes of CSDH. Methods We studied 131 CSDH patients who had undergone single burr hole drainage surgery. The images of the subdural hematomas on preoperative DW-MRI and computed tomography (CT) were divided into three groups based on their signal intensity and density: 1) homogeneous (iso or low) density on CT and homogeneous low signal intensity on DW-MRI; 2) homogeneous (iso or low) density on CT and mixed signal intensity on DW-MRI; and 3) heterogeneous density on CT and mixed signal intensity on DW-MRI. On the basis of postoperative CT, we also divided the patients into 3 groups of surgical outcomes according to residual hematoma and mass effect. Results Analysis showed statistically significant differences in surgical (A to B: p<0.001, A to C: p<0.001, B to C: p=0.129) and functional (A to B: p=0.039, A to C: p<0.001, B to C: p=0.108) outcomes and treatment failure rates (A to B: p=0.037, A to C: p=0.03, B to C: p=1) between the study groups. In particular, group B and group C showed worse outcomes and higher treatment failure rates than group A. Conclusion CSDH with homogeneous density on CT was characterized by signal intensity on DW-MRI. In CSDH patients, performing DW-MRI as well as CT helps to predict postoperative treatment failure or complications.
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Affiliation(s)
- Seung-Hwan Lee
- Department of Neurosurgery, Korea University Medical Center, Ansan, Korea
| | - Jong-Il Choi
- Department of Neurosurgery, Hallym University Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Dong-Jun Lim
- Department of Neurosurgery, Korea University Medical Center, Ansan, Korea
| | - Sung-Kon Ha
- Department of Neurosurgery, Korea University Medical Center, Ansan, Korea
| | - Sang-Dae Kim
- Department of Neurosurgery, Korea University Medical Center, Ansan, Korea
| | - Se-Hoon Kim
- Department of Neurosurgery, Korea University Medical Center, Ansan, Korea
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18
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Yamada SM, Tomita Y, Murakami H, Nakane M, Yamada S, Murakami M, Hoya K, Nakagomi T, Tamura A, Matsuno A. Headache in patients with chronic subdural hematoma: analysis in 1080 patients. Neurosurg Rev 2017; 41:549-556. [PMID: 28815322 DOI: 10.1007/s10143-017-0889-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 07/13/2017] [Accepted: 07/31/2017] [Indexed: 11/26/2022]
Abstract
Headache is a major symptom in chronic subdural hematoma (CSDH) patients. However, some CSDH patients do not complain headache although the hematoma is thick with definite midline shift. This clinical study was performed to identify the mechanism of headache in CSDH patients. We compiled clinical data of 1080 surgically treated CSDH patients (711 males and 369 females), and in 54 cases, the pressure of hematoma was measured during burr hole surgery using a glass-stick manometer. Headache was recognized in 22.6% of patients, while nausea or vomit suggesting increased intracranial pressure was detected in only 3.0%. Ophthalmological examination was performed in 238 patients, and papilledema was identified in only one patient (0.4%). The mean age of patients with headache (59.8 ± 16.9 years) was significantly younger than that of those without (75.7 ± 11.2 years) (P < 0.01). In 54 cases, the mean hematoma pressure was not significantly different between patients with (17.1 ± 6.2 mmH2O) and without (18.4 ± 7.2 mmH2O) headache (P > 0.10). Hematoma thickness was significantly greater in patients without headache (P < 0.01), but the ratio of midline shift to hematoma thickness was significantly greater in patients with headache (P < 0.01). In our results, the status of increased intracranial pressure was rare in CSDH patients, and high hematoma pressure was not a cause of headache. Midline shift was the most influenced factor for headache in our study, and based on the results, the authors consider that the potential cause of headache in CSDH might be stretching or twisting of the pain-sensitive meninges and meningeal arteries or veins.
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Affiliation(s)
- Shoko M Yamada
- Department of Neurosurgery, Teikyo University Mizonokuchi Hospital, 5-1-1 Futago, Takatsu-ku, Kawasaki, Kanagawa, 213-8507, Japan.
| | - Yusuke Tomita
- Department of Neurosurgery, Teikyo University Mizonokuchi Hospital, 5-1-1 Futago, Takatsu-ku, Kawasaki, Kanagawa, 213-8507, Japan
| | - Hideki Murakami
- Department of Neurosurgery, Teikyo University Mizonokuchi Hospital, 5-1-1 Futago, Takatsu-ku, Kawasaki, Kanagawa, 213-8507, Japan
| | - Makoto Nakane
- Department of Neurosurgery, Teikyo University Mizonokuchi Hospital, 5-1-1 Futago, Takatsu-ku, Kawasaki, Kanagawa, 213-8507, Japan
| | - So Yamada
- Department of Neurosurgery, Teikyo University Chiba Medical Center, 3426-3 Anesaki, Ichihara-city, Chiba, 299-0111, Japan
| | - Mineko Murakami
- Department of Neurosurgery, Teikyo University Chiba Medical Center, 3426-3 Anesaki, Ichihara-city, Chiba, 299-0111, Japan
| | - Katsumi Hoya
- Department of Neurosurgery, Teikyo University Chiba Medical Center, 3426-3 Anesaki, Ichihara-city, Chiba, 299-0111, Japan
| | - Tadayoshi Nakagomi
- Department of Neurosurgery, Teikyo University Hospital, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8606, Japan
| | - Akira Tamura
- Department of Neurosurgery, Teikyo University Hospital, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8606, Japan
| | - Akira Matsuno
- Department of Neurosurgery, Teikyo University Hospital, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8606, Japan
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Mahmood SD, Waqas M, Baig MZ, Darbar A. Mini-Craniotomy Under Local Anesthesia for Chronic Subdural Hematoma: An Effective Choice for Elderly Patients and for Patients in a Resource-Strained Environment. World Neurosurg 2017; 106:676-679. [PMID: 28735131 DOI: 10.1016/j.wneu.2017.07.057] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 07/09/2017] [Accepted: 07/11/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND Mini-craniotomy for chronic subdural hematoma (CSDH) is associated with lower rates of recurrence. However, the procedure is performed mostly with the patient under general anesthesia (GA) and therefore frequently requires an intensive care unit (ICU) facility, especially in the elderly population. Because of the unavailability of ICU beds, and to avoid GA, we started to perform this procedure with the patient under local anesthesia (LA). MATERIALS AND METHODS This was a retrospective medical chart review conducted in the section of Neurosurgery at the Aga Khan Hospital in Karachi, Pakistan. The study duration was 1 year. We included patients aged 55 years or older undergoing surgery for CSDH. Clinical characteristics, hospital stay, and recurrence rates were compared between 2 groups, local versus general anesthesia. RESULTS Thirty-five patients underwent mini-craniotomy for CSDH in the study period. Sixteen patients underwent mini-craniotomy under LA versus 19 patients for GA. Median age for the LA group was 67 years compared with 70 years in the GA group. Four patients from the LA group experienced postoperative complications versus 7 from the GA group. Only one patient in the LA group required an ICU bed in the postoperative period. There was no recurrence in LA group. The overall recurrence was 2.86%. CONCLUSIONS Mini-craniotomy for CSDH under LA is an equally effective procedure compared with mini-craniotomy under GA. In addition, it minimizes the risks of GA in the elderly population and obviates the need of a postoperative ICU bed. It also reduces operative time and hospital stay as compared with GA.
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Affiliation(s)
| | - Muhammad Waqas
- Section of Neurosurgery, Division of Surgery, The Aga Khan University Hospital, Karachi, Pakistan
| | - Mirza Zain Baig
- Medical College, The Aga Khan University Hospital, Karachi, Pakistan
| | - Aneela Darbar
- Section of Neurosurgery, Division of Surgery, The Aga Khan University Hospital, Karachi, Pakistan.
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Desai VR, Scranton RA, Britz GW. Management of Recurrent Subdural Hematomas. Neurosurg Clin N Am 2017; 28:279-286. [DOI: 10.1016/j.nec.2016.11.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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21
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Stavrinou P, Katsigiannis S, Lee JH, Hamisch C, Krischek B, Mpotsaris A, Timmer M, Goldbrunner R. Risk Factors for Chronic Subdural Hematoma Recurrence Identified Using Quantitative Computed Tomography Analysis of Hematoma Volume and Density. World Neurosurg 2016; 99:465-470. [PMID: 28017760 DOI: 10.1016/j.wneu.2016.12.058] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Revised: 12/11/2016] [Accepted: 12/14/2016] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Chronic subdural hematoma (CSDH), a common condition in elderly patients, presents a therapeutic challenge with recurrence rates of 33%. We aimed to identify specific prognostic factors for recurrence using quantitative analysis of hematoma volume and density. METHODS We retrospectively reviewed radiographic and clinical data of 227 CSDHs in 195 consecutive patients who underwent evacuation of the hematoma through a single burr hole, 2 burr holes, or a mini-craniotomy. To examine the relationship between hematoma recurrence and various clinical, radiologic, and surgical factors, we used quantitative image-based analysis to measure the hematoma and trapped air volumes and the hematoma densities. RESULTS Recurrence of CSDH occurred in 35 patients (17.9%). Multivariate logistic regression analysis revealed that the percentage of hematoma drained and postoperative CSDH density were independent risk factors for recurrence. All 3 evacuation methods were equally effective in draining the hematoma (71.7% vs. 73.7% vs. 71.9%) without observable differences in postoperative air volume captured in the subdural space. CONCLUSIONS Quantitative image analysis provided evidence that percentage of hematoma drained and postoperative CSDH density are independent prognostic factors for subdural hematoma recurrence.
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Affiliation(s)
- Pantelis Stavrinou
- Department of Neurosurgery, University Hospital of Cologne, Cologne, Germany.
| | | | - Jong Hun Lee
- Department of Neurosurgery, University Hospital of Cologne, Cologne, Germany
| | - Christina Hamisch
- Department of Neurosurgery, University Hospital of Cologne, Cologne, Germany
| | - Boris Krischek
- Department of Neurosurgery, University Hospital of Cologne, Cologne, Germany
| | | | - Marco Timmer
- Department of Neurosurgery, University Hospital of Cologne, Cologne, Germany
| | - Roland Goldbrunner
- Department of Neurosurgery, University Hospital of Cologne, Cologne, Germany
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Qian Z, Yang D, Sun F, Sun Z. Risk factors for recurrence of chronic subdural hematoma after burr hole surgery: potential protective role of dexamethasone. Br J Neurosurg 2016; 31:84-88. [PMID: 27899031 DOI: 10.1080/02688697.2016.1260686] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Zhongrun Qian
- Department of Neurosurgery, Ren Ji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Dianxu Yang
- Department of Neurosurgery, Ren Ji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Fei Sun
- Department of Neurosurgery, The Affiliated Xuzhou Hospital of Medical College of Southeast University, Xuzhou, Jiangsu, China
| | - Zhenguo Sun
- Department of Neurosurgery, The Affiliated Xuzhou Hospital of Medical College of Southeast University, Xuzhou, Jiangsu, China
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Yan K, Gao H, Wang Q, Xu X, Wu W, Zhou X, Xu W, Ye F. Endoscopic surgery to chronic subdural hematoma with neovessel septation: technical notes and literature review. Neurol Res 2016; 38:467-76. [DOI: 10.1080/01616412.2016.1139772] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Preoperative predictive factors for surgical and functional outcomes in chronic subdural hematoma. Acta Neurochir (Wien) 2016; 158:135-9. [PMID: 26602235 DOI: 10.1007/s00701-015-2625-z] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 10/23/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Chronic subdural hematoma (CSDH) is a frequently encountered neurosurgical condition, especially in the elderly. We investigated predictive factors for surgical and functional outcomes after burr-hole drainage (BHD) surgery. METHODS All patients with CSDH treated by BHD between January 2012 and December 2014 were included in this study. All patients were classified by symptom, clinical grade, time, location, hematoma density, midline shift, and other characteristics. Pre- and postoperative CT evaluation was performed at 0, 3, and 6 months. Clinical grades were classified as described in Markwalder et al. Surgical and clinical outcomes were evaluated with the brain expansion rate and modified Rankin Scale (mRS). Brain expansion rate was calculated as the ratio between post- and pre-operative hematoma thickness. Recurrence was defined as the occurrence of symptoms and hematoma on CT within 6 months. RESULTS This study included 130 patients over 2 years. Among the variable parameters, young age (<75), iso-density of hematoma on CT, and short duration from symptom to surgery were correlated with good brain expansion. Patients with good brain expansion had fewer recurrences. In terms of mRS, young age, iso-density, and good clinical grade were correlated with good functional outcomes. CONCLUSIONS Clinicians should be more aware of general conditions and medical problems, especially in elderly patients. Membranectomy should be considered in patients with a long duration of symptoms or hypo-dense hematomas to promote good brain expansion and good mRS scores.
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FARHAT NETO JAMIL, Araujo JLV, Ferraz VR, Haddad L, Veiga JCE. Chronic subdural hematoma: epidemiological and prognostic analysis of 176 cases. Rev Col Bras Cir 2015; 42:283-7. [DOI: 10.1590/0100-69912015005003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 05/10/2015] [Indexed: 11/22/2022] Open
Abstract
Objective : To characterize patients with chronic subdural hematoma undergoing surgery and to identify prognostic indicators. Methods : We conducted a retrospective analysis of patients diagnosed with chronic subdural hematoma (CSDH) undergoing surgical treatment. We analyzed: age, period from trauma to diagnostic imaging, pre and postoperative Glasgow coma scale, type of surgery, associated comorbidities, use of postoperative drainage and outpatient treatment. Results : The sample consisted of 176 patients, 126 male and 50 female patients (ratio 2.5 : 1), ages ranged from six months to 97 years, with an average of 59.3 years. CSDH was caused by trauma in 52% of patients, with the time from trauma to imaging averaging 25.05 days; 37.7% were hypertensive patients and 20% had a neurological disease. Eighty-five (48.3%) patients were elderly and altered consciousness was present in 63% of cases. Of the 91 (51.7%) non-elderly patients, 44% presented with headache, altered consciousness occurred in 40% and motor abnormalities in 27.5%. The CSDH was located on the right in 41%, left in 43% and bilaterally in 16% of patients. Conclusion : the change of consciousness was the most common clinical alteration in the elderly and headache in non-elderly. The most associated comorbidity was the arterial hypertension and the most frequent cause, head trauma. The trepanation with two oriffices associated with a closed drainage system was the most used operating, with high efficacy and low complication rate.
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Jung YG, Jung NY, Kim E. Independent predictors for recurrence of chronic subdural hematoma. J Korean Neurosurg Soc 2015; 57:266-70. [PMID: 25932293 PMCID: PMC4414770 DOI: 10.3340/jkns.2015.57.4.266] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 01/19/2015] [Accepted: 01/20/2015] [Indexed: 11/27/2022] Open
Affiliation(s)
- Yoon-Gyo Jung
- Department of Neurosurgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Na-Young Jung
- Department of Neurosurgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - El Kim
- Department of Neurosurgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
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27
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Lee CC, Chen CJ, Ball B, Schlesinger D, Xu Z, Yen CP, Sheehan J. Stereotactic radiosurgery for arteriovenous malformations after Onyx embolization: a case-control study. J Neurosurg 2015; 123:126-35. [PMID: 25658780 DOI: 10.3171/2014.12.jns141437] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Onyx, an ethylene-vinyl alcohol copolymer mixed in a dimethyl sulfoxide solvent, is currently one of the most widely used liquid materials for embolization of intracranial arteriovenous malformations (AVMs). The goal of this study was to define the risks and benefits of stereotactic radiosurgery (SRS) for patients who have previously undergone partial AVM embolization with Onyx. METHODS Among a consecutive series of 199 patients who underwent SRS between January 2007 and December 2012 at the University of Virginia, 25 patients had Onyx embolization prior to SRS (the embolization group). To analyze the obliteration rates and complications, 50 patients who underwent SRS without prior embolization (the no-embolization group) were matched by propensity score method. The matched variables included age, sex, nidus volume before SRS, margin dose, Spetzler-Martin grade, Virginia Radiosurgery AVM Scale score, and median imaging follow-up period. RESULTS After Onyx embolization, 18 AVMs were reduced in size. Total obliteration was achieved in 6 cases (24%) at a median of 27.5 months after SRS. In the no-embolization group, total obliteration was achieved in 20 patients (40%) at a median of 22.4 months after SRS. Kaplan-Meier analysis demonstrated obliteration rates of 17.7% and 34.1% in the embolization group at 2 and 4 years, respectively. In the no-embolization group, the corresponding obliteration rates were 27.0% and 55.9%. The between-groups difference in obliteration rates after SRS did not achieve statistical significance. The difference in complications, including adverse radiation effects, hemorrhage episodes, seizure control, and patient mortality also did not reach statistical significance. CONCLUSIONS Onyx embolization can effectively reduce the size of many AVMs. This case-control study did not show any statistically significant difference in the rates of embolization or complications after SRS in patients who had previously undergone Onyx embolization and those who had not.
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Affiliation(s)
- Cheng-Chia Lee
- Departments of 1 Neurological Surgery, and.,Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital; and.,School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | | | | | - David Schlesinger
- Departments of 1 Neurological Surgery, and.,Radiation Oncology, University of Virginia, Charlottesville, Virginia
| | - Zhiyuan Xu
- Departments of 1 Neurological Surgery, and
| | | | - Jason Sheehan
- Departments of 1 Neurological Surgery, and.,Radiation Oncology, University of Virginia, Charlottesville, Virginia
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Kim BJ, Park KJ, Park DH, Lim DJ, Kwon TH, Chung YG, Kang SH. Risk factors of delayed surgical evacuation for initially nonoperative acute subdural hematomas following mild head injury. Acta Neurochir (Wien) 2014; 156:1605-13. [PMID: 24943910 DOI: 10.1007/s00701-014-2151-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Accepted: 05/29/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Although the majority of patients with minimal acute subdural hematomas (aSDHs) can be managed conservatively, some require delayed aSDH evacuation due to hematoma enlargement. This study was designed to determine the risk factors associated with delayed hematoma enlargement leading to surgery in patients with aSDHs who did not initially require surgical intervention. METHODS From 2002 to 2012, 98 patients were treated for nonoperative aSDHs following mild head injury (Glasgow Coma Scale scores of 13-15). The outcome variables were radiographic evidence of SDH enlargement on serially obtained computed tomography (CT) images and later surgical evacuation. Univariate and multivariate analyses were applied to both the demographic and initial radiographic features to identify risk factors for SDH progression and surgery. RESULTS Overall, 64 patients (65 %) revealed minimal SDH or spontaneous hematoma resolution (conservative group) with conservative management at their last follow-up CT scan. The remaining 34 patients (35 %) received delayed hematoma evacuation (delayed surgery group) a median of 17 days after the head trauma. There were no significant differences between the two groups for baseline characteristics, including age, injury type, degree of brain atrophy, prior history of antithrombotic drugs, and coagulopathy. The presence of cerebral contusions and subarachnoid hemorrhages was more common in the conservative group (p = 0.003 and p = 0.003, respectively). On multivariate analysis, hematoma volume (p = 0.01, odds ratio [OR] = 1.094, 95 % confidence interval [CI] = 1.021-1.173) and degree of midline shift (p = 0.01, OR = 1.433, 95 % CI = 1.088-1.888) on the initial CT scan were independently associated with delayed hematoma evacuation. CONCLUSIONS A critical proportion of patients with minimal aSDHs occurring after mild head injury can progress over several weeks and require hematoma evacuation. Especially patients with a large initial SDH volume and accompanying midline shift require careful monitoring of hematoma progression.
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Affiliation(s)
- Bum-Joon Kim
- Department of Neurosurgery, Korea University College of Medicine, #126, 5-ga, Anam-Dong, Seongbuk-Gu, Seoul, 136-705, Korea
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Xu FF, Chen JH, Leung GKK, Hao SY, Xu L, Hou ZG, Mao X, Shi GZ, Li JS, Liu BY. Quantitative computer tomography analysis of post-operative subdural fluid volume predicts recurrence of chronic subdural haematoma. Brain Inj 2014; 28:1121-6. [DOI: 10.3109/02699052.2014.910702] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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30
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Posicionamiento postoperatorio de la cabecera tras drenaje de hematomas subdurales crónicos por trepanación: Revisión sistemática y metaanálisis de estudios controlados aleatorizados. Neurocirugia (Astur) 2014; 25:99-107. [DOI: 10.1016/j.neucir.2013.11.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Revised: 10/21/2013] [Accepted: 11/28/2013] [Indexed: 11/22/2022]
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Satyarthee GD, Pankaj D, Sharma BS. "Rabbit Ear" scalp deformity caused by massive subdural effusion in infant following bilateral burr-hole drainage. J Pediatr Neurosci 2014; 8:235-8. [PMID: 24470822 PMCID: PMC3888045 DOI: 10.4103/1817-1745.123690] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Subdural effusion (SDE) in an infant is a rare clinical scenario, which may be secondary to a variety of etiologies. Massive SDE is an extremely rare complication of head injury. It usually runs a self-limiting course. Though neurosurgical intervention is occasionally needed, different methods of surgical procedure for management includes burr-hole alone, burr-holes with subdural drain placement, twist drill craniotomy with drain and even craniotomy. The authors report a rare case of progressive massive SDE, which despite bilateral burr-hole placement and drainage failed and presented with visual deterioration and massive bulge of scalp at burr-hole sites producing rabbit ear sign in a 10 month old infant. Ultimately cystoperitoneal shunt was carried out in a desperate attempt to prevent impending rupture of scalp sutures at sites of previous burr-hole placement. Astonishingly not only complete resolution of hygroma, but visual recovery also took place. Patient is doing well at 6 months following shunt with regaining normal vision and appropriate developmental milestones. A magnetic resonance imaging scan of brain at last follow-up revealed mild ventriculomegaly with subduro-peritoneal shunt in situ and rest of brain was unremarkable. Such cases have not been reported in literature until date.
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Affiliation(s)
- Guru Dutta Satyarthee
- Department of Neurosurgery, All India Institute of Medical Sciences and Associated Jai Prakash Narayan Apex Trauma Centre, New Delhi, India
| | - Dawar Pankaj
- Department of Neurosurgery, All India Institute of Medical Sciences and Associated Jai Prakash Narayan Apex Trauma Centre, New Delhi, India
| | - B S Sharma
- Department of Neurosurgery, All India Institute of Medical Sciences and Associated Jai Prakash Narayan Apex Trauma Centre, New Delhi, India
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KAYACI S, KANAT A, KOKSAL V, OZDEMIR B. Effect of inner membrane tearing in the treatment of adult chronic subdural hematoma: a comparative study. Neurol Med Chir (Tokyo) 2014; 54:363-73. [PMID: 24477064 PMCID: PMC4533437 DOI: 10.2176/nmc.oa.2013-0147] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Accepted: 10/01/2013] [Indexed: 12/04/2022] Open
Abstract
The postoperative results of chronic subdural hematoma (CSDH) procedures using catheterization and tearing of inner membrane (CTIM) technique have not previously been discussed in the literature. This article compares the effects of CTIM technique on brain re-expansion and re-accumulation with cases operated on with a burr-hole craniotomy and outer membrane incision (BCOMI) technique. The study involved operations on 144 patients (Group 1) using the CTIM technique and 108 patients (Group 2) using the BCOMI technique. In the operations using the CTIM technique in Group 1, the mean effusion measured in the subdural space (SDS) was 10.0 ± 0.2 mm, and for Group 2, 14.3 ± 0.6 mm in the postoperative period on the first and third days and this difference was found to be significant (p < 0.05). The means were 6.6 ± 0.2 mm for Group 1 and 10.3 ± 0.5 mm for Group 2 on the seventh day (p < 0.05). Recurrence rate was 8.3% in Group 2 and 0 in Group 1. This difference was statistically significant (p = 0001). The length of hospital stay was 7.0 ± 0.1 days for the Group 1 and 8.8 ± 0.2 days for Group 2 and this difference was significant (p < 0.05). These results indicate that the CTIM technique is preferable because it results in earlier re-expansion, lower recurrence, less subdural effusion and pneumocephalus, and shorter hospital stays.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Craniotomy/instrumentation
- Craniotomy/methods
- Female
- Glasgow Coma Scale
- Hematoma, Subdural, Chronic/diagnostic imaging
- Hematoma, Subdural, Chronic/epidemiology
- Hematoma, Subdural, Chronic/pathology
- Hematoma, Subdural, Chronic/surgery
- Humans
- Length of Stay/statistics & numerical data
- Male
- Membranes/surgery
- Middle Aged
- Pneumocephalus/epidemiology
- Pneumocephalus/etiology
- Postoperative Complications/epidemiology
- Postoperative Complications/etiology
- Postoperative Complications/prevention & control
- Recurrence
- Retrospective Studies
- Suction
- Tomography, X-Ray Computed
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Affiliation(s)
- Selim KAYACI
- Department of Neurosurgery, Recep Tayyip Erdogan University, Rize, Turkey
| | - Ayhan KANAT
- Department of Neurosurgery, Recep Tayyip Erdogan University, Rize, Turkey
| | - Vaner KOKSAL
- Department of Neurosurgery, Recep Tayyip Erdogan University, Rize, Turkey
| | - Bulent OZDEMIR
- Department of Neurosurgery, Recep Tayyip Erdogan University, Rize, Turkey
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"Rabbit ear" scalp deformity caused by massive subdural effusion in infant following bilateral bur-hole drainage failure: successfully managed with subduro-peritoneal shunt. Childs Nerv Syst 2013; 29:1993-6. [PMID: 23881426 DOI: 10.1007/s00381-013-2233-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Accepted: 07/12/2013] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Subdural effusion in an infant is a rare clinical scenario which may be secondary to a variety of etiologies. Massive subdural effusion is an extremely rare complication of head injury. CASE REPORT Authors report a rare case of progressive massive subdural effusion which, despite bilateral bur-hole placement and drainage, failed and presented with visual deterioration and massive bulge of the scalp at bur-hole sites, producing a rabbit ear appearance in a 10-month-old infant. Ultimately, cystoperitoneal shunt was carried out in a desperate attempt to prevent impending rupture of scalp sutures at sites of previous bur-hole placement. This was followed by not only complete resolution of hygroma but also visual recovery. The patient is doing well at 6 months following shunt, regaining normal vision and appropriate developmental milestones. A MRI scan of the brain was carried out at last follow-up, which revealed mild ventriculomegaly with the rest of the brain being unremarkable, and subduro-peritoneal shunt in situ. Such a case has not been reported in the literature till date. DISCUSSION Subdural effusion usually runs a self-limiting course. Though neurosurgical intervention is occasionally needed, different methods of surgical procedure for management include bur hole alone, bur holes with subdural drain placement, twist drill craniotomy with drain, and even craniotomy. Various methods of management are discussed along with a review of pertinent literature.
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Lee GY, Oh CH, Shim YS, Yoon SH, Park HC, Park CO, Hyun D. Comparison of drainage volume of chronic subdural hematoma according to drainage catheter type. Yonsei Med J 2013; 54:1091-7. [PMID: 23918556 PMCID: PMC3743203 DOI: 10.3349/ymj.2013.54.5.1091] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE To assess the therapeutic value of two different drainage catheters in treating chronic subdural hematoma (CSDH). MATERIALS AND METHODS Two types of drainage catheters can be used to treat CSDH according to the position of holes in the catheter: open-type or closed-type catheter. In this retrospective study, 199 total patients with CSDH were reviewed according to catheter type. Among them, 84 patients were and 113 in the closed-type group (holes positioned within the distal- most 1 cm of the catheter). The surgeon selected the catheter type. Total drainage volume, initial drainage volume within 2 days, percentage of initial drainage volume per total drainage volume, duration of catheter insertion, and reoperation rate were compared. RESULTS Total drainage volume was not different between the two groups (p=0.333). The initial drainage volume within 2 days was larger in the open-type group than closed-type group (p=0.024), but the percentage of initial drainage volume per total drainage volume was not different (p=0.354). The duration of catheter insertion was shorter in the open-type group than closed-type group (p=0.015). The reoperation rate of CSDH was also higher in the open-type group than closed-type group (p=0.004). CONCLUSION CSDH drainage with an open-type catheter is faster compared with a closed-type catheter, but total drainage volume is similar and reoperation rate is higher. Therefore, the open-type catheter for CSDH drainage has limited clinical value.
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Affiliation(s)
- Gun-Young Lee
- Department of Neurosurgery, School of Medicine, Inha University, Incheon, Korea
| | - Chang Hyun Oh
- Department of Neurosurgery, Guro Teun Teun Hospital, Seoul, Korea
| | - Yu Shik Shim
- Department of Neurosurgery, School of Medicine, Inha University, Incheon, Korea
| | - Seung Hwan Yoon
- Department of Neurosurgery, School of Medicine, Inha University, Incheon, Korea
| | - Hyeong-Chun Park
- Department of Neurosurgery, School of Medicine, Inha University, Incheon, Korea
| | - Chong Oon Park
- Department of Neurosurgery, School of Medicine, Inha University, Incheon, Korea
| | - Dongkeun Hyun
- Department of Neurosurgery, School of Medicine, Inha University, Incheon, Korea
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de Araújo Silva DO, Matis GK, Costa LF, Kitamura MAP, de Carvalho Junior EV, de Moura Silva M, Barbosa BJAP, Pereira CU, da Silva JC, Birbilis TA, de Azevedo Filho HRC. Chronic subdural hematomas and the elderly: Surgical results from a series of 125 cases: Old "horses" are not to be shot! Surg Neurol Int 2012; 3:150. [PMID: 23372967 PMCID: PMC3551521 DOI: 10.4103/2152-7806.104744] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Accepted: 09/27/2012] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND To present the accumulated experience from treating chronic subdural hematomas (CSDH) in a local hospital of a third world country. METHODS One hundred and twenty-five consecutive patients with CSDH who were surgically treated in the Neurosurgical Department of the Hospital da Restauração, Recife-PE, Brazil, between January 2006 and May 2008, were retrospectively studied. Glasgow Outcome Scale (GOS) was employed to define outcome at 6 months as good (GOS 4 and 5) or poor (GOS ≤ 3). Age, admission Glasgow Coma Scale (GCS), location of hematomas (unilateral/bilateral), drainage system placement and recurrence were all analyzed for potential impact on final outcome. RESULTS The median age was 69 years, with a male/female ratio of 102/23. History of trauma was present in 60.8% of the patients. The median GCS on admission was 14. In 64 patients, the hematoma was on the left side, while in 42 patients it was on the right side. Bilateral hematomas were present in 19 cases (15.2%). Drainage systems were used in 93.6% of the cases. Recurrence occurred in 8.8% of the patients. One hundred and three patients obtained a good outcome at 6 months. The mortality rate was 11.2%. Patients with GCS ≥9 on admission presented better outcome (P < 0.05). Recurrent cases presented a poor outcome (P < 0.05). CONCLUSIONS This study suggests that the main factors associated with outcome in patients harboring CSDH are the admission GCS score and the recurrence status. Advanced age is not a contraindication for surgical treatment. This study, solely focused on the Brazilian population, is the first of its kind in the English literature, and it could serve as a useful introduction to a more complex, multivariate, debate.
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Singla A, Jacobsen WP, Yusupov IR, Carter DA. Subdural evacuating port system (SEPS)--minimally invasive approach to the management of chronic/subacute subdural hematomas. Clin Neurol Neurosurg 2012; 115:425-31. [PMID: 22763191 DOI: 10.1016/j.clineuro.2012.06.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2012] [Revised: 05/13/2012] [Accepted: 06/10/2012] [Indexed: 12/01/2022]
Abstract
OBJECTIVE The population suffering from chronic/subacute subdural hematomas (SDHs) generally includes elderly patients with co-morbidities; therefore the success of less invasive surgical techniques has been of long standing interest. The optimum treatment option for chronic/subacute SDH has not been well established. We report our retrospective outcomes of SDH drainage through a subdural evacuating port system (SEPS). PATIENTS AND METHODS Fifty-two consecutive adult patients with chronic/subacute SDH treated with SEPS (total 64 procedures), over a period of 3 years (June 2006-June 2009), were included. 9/52 patients had SEPS performed for bilateral SDHs. Three patients had SEPS placed for recurrent SDH. This retrospective study was approved by the Institutional Review Board of SUNY Upstate Medical University and Crouse Hospital. RESULTS Overall 38/52 patients (73%) showed clinical improvement, 10/52 patients (19%) did not show any clinical improvement and 4/52 (8%) patients became clinically worse after the SEPS placement during initial hospitalization. 41/52 patients, treated initially with SEPS were followed as outpatients. 32/41 patients improved, returning to baseline neurological status, 5/41 patients improved, but still had some residual symptoms. The remaining 4/41 patients, presented with recurrent symptoms and had recurrent SDH on CT scans. During the in-hospital post-SEPS period, 8 SDH had >75% decrease, 17 SDH had between 50 and 75% decrease, 23 SDH had between 25 and 50% decrease and 14 procedures had <25% decrease in maximal width of the SDH on postoperative scans. Outpatient follow up CT scans after SEPS placement were available for 46/64 procedures. At final outpatient follow up, 33/46 SDHs showed >75% decrease in maximal thickness, 4/46 SDH showed between 50 and 75% and 2/46 SDH showed between 25 and 50% decreases in maximal width of chronic SDH. However, in 7/46 patients, SDH re-accumulated (i.e. increased in thickness) as outpatients, after initial response to treatment on post-operative in-hospital CT scans. CONCLUSION SEPS is an effective, relatively safe and convenient treatment strategy with low invasiveness; among management options of chronic/subacute SDH.
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Affiliation(s)
- Amit Singla
- Department of Neurosurgery, SUNY Upstate Medical University, 750 East Adams Street, Syracuse, NY 13210, United States.
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Goldstein H, Sonabend AM, Connolly ES. Chronic Subdural Hematomas: Perspective on Current Treatment Paradigms. World Neurosurg 2012; 78:66-8. [DOI: 10.1016/j.wneu.2011.10.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2011] [Accepted: 10/06/2011] [Indexed: 11/26/2022]
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Ohba S, Kinoshita Y, Nakagawa T, Murakami H. The risk factors for recurrence of chronic subdural hematoma. Neurosurg Rev 2012; 36:145-9; discussion 149-50. [PMID: 22696158 DOI: 10.1007/s10143-012-0396-z] [Citation(s) in RCA: 99] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2011] [Revised: 10/18/2011] [Accepted: 04/14/2012] [Indexed: 12/15/2022]
Abstract
Chronic subdural hematoma (CSDH) is a common disease in the elderly, and the recurrence rate of CSDH is reported to range from 2.3 to 33%. We performed a retrospective review of a number of CSDH cases and the potential factors associated with CSDH recurrence. The patient population comprised 112 men and 65 women with a mean age of 74.7 years. We analyzed the following factors: age, sex, antiplatelet and anticoagulant use, hematoma laterality, hematoma thickness, degree of midline shift and internal architecture of the hematoma in the preoperative CT films, use of irrigation, direction of the drainage tube, width of the subdural space, and degree of midline shift and the presence of a massive subdural air collection in the postoperative CT films. Univariate analysis revealed that there was a trend for different rates of recurrence among the different types of hematomas. The presence of a postoperative massive subdural air collection tended to be associated with the recurrence of hematoma. Multivariate analysis revealed that separated hematomas were significantly associated with CSDH recurrence, whereas the presence of postoperative massive subdural air collection tended to be associated with hematoma recurrence. Neither univariate nor multivariate analysis could demonstrate an association between the direction of the drainage tube and the recurrence of CSDH.
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Affiliation(s)
- Shigeo Ohba
- Department of Neurosurgery, Ashikaga Red Cross Hospital, 3-2100 Honjo, Ashikaga City, Tochigi, 326-0808, Japan.
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Tahsim-Oglou Y, Beseoglu K, Hänggi D, Stummer W, Steiger HJ. Factors predicting recurrence of chronic subdural haematoma: the influence of intraoperative irrigation and low-molecular-weight heparin thromboprophylaxis. Acta Neurochir (Wien) 2012; 154:1063-7; discussion 1068. [PMID: 22476866 DOI: 10.1007/s00701-012-1334-0] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2012] [Accepted: 03/15/2012] [Indexed: 11/30/2022]
Abstract
BACKGROUND Burr-hole drainage has become the accepted treatment of choice for chronic subdural haematoma (cSDH), although still burdened with a major recurrence rate. The current analysis was initiated to determine management-related risk factors for recurrence, i.e. postoperative low-molecular-weight heparin thromboprophylaxis, and the importance of rinsing the subdural space. METHODS Two-hundred and forty-seven patients with computerised tomography (CT) defined symptomatic cSDH were managed by two burr-hole trepanations and drainage between January 2005 and November 2008. Postoperative thromboprophylaxis with 40 mg enoxaparine daily was given only during the first half of the study period. For the current analysis the amount of rinsing fluid, postoperative low-dose thromboprophylaxis, as well as age and gender, bilaterality, preoperative and postoperative blood coagulation studies, platelet counts and decrease of subdural fluid on early postoperative CT, were recorded and correlated with recurrence. Statistical calculation was done by univariate and multivariate analysis. RESULTS A total of 62 of 247 patients needed revision surgery for recurrence (25.1 %). Recurrence rates were significantly lower in the patients treated without postoperative enoxaparine (18.84 %) than in the group with postoperative low-dose enoxaparine thromboprophylaxis (32.11 %) and enoxaparine was administered in a higher proportion of the patients suffering recurrence (P = 0.013). A median intraoperative irrigation volume of 863 ml saline was used in the patients suffering recurrence and 1,500 ml in patients without recurrence (P < 0.001). The median age was slightly higher in the patients suffering from recurrence. Male gender predominated in both groups but was slightly more pronounced in the recurrence group. Preoperative and postoperative platelet counts and plasmatic coagulation indices did not differ significantly between the groups. Relative residual subdural fluid collection on early postoperative CT remained larger in patients finally suffering recurrence (P = 0.03). Multivariate analysis confirmed a small amount of rinsing fluid, male gender and the use of enoxaparine as the most important risk factors for recurrence, although that latter factor did not reach statistical significance in the multivariate analysis. CONCLUSIONS The investigation provides evidence that copious intraoperative irrigation and avoidance of postoperative low-molecular-weight heparin thromboprophylaxis may reduce the recurrence rate of cSDH.
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Nayil K, Ramzan A, Sajad A, Zahoor S, Wani A, Nizami F, Laharwal M, Kirmani A, Bhat R. Subdural hematomas: an analysis of 1181 Kashmiri patients. World Neurosurg 2012; 77:103-10. [PMID: 22405391 DOI: 10.1016/j.wneu.2011.06.012] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2011] [Revised: 04/11/2011] [Accepted: 06/02/2011] [Indexed: 11/18/2022]
Abstract
BACKGROUND We endeavored to analyze patients of subacute and chronic subdural hematomas studied in a 4-year period at the Sher-i-Kashmir Institute of Medical Sciences, Kashmir, India. METHODS The study was a retrospective analysis of 1181 patients of subdural hematomas. Demographic characteristics, clinico-radiologic features, operative modalities, and outcome were studied. Acute subdural hematomas were excluded from the study. RESULTS The mean age was 60.4 ± 12.4 and males outnumbered females. Chronic subdural collections were more common than subacute subdural hematomas and left side predominated. Two burr holes with closed-system drainage was used in most patients. Incidence of postoperative seizures is very low. Overall recurrence rates were low; however, multilocular hematomas had the highest incidence of recurrence. Morbidity and mortality were 7.53% and 2.96%, respectively. Preoperative neurologic grade correlated with outcome. CONCLUSIONS Subdural hematomas are common in elderly males. Preoperative neurologic grade dictates the outcome. Multilocular hematomas have a higher chance of recurrence. Craniotomy should be reserved for recurrent hematomas, and there may be a scope of craniotomy for multilocular chronic subdural hematomas at the outset. Antiepileptic prophylaxis is not routinely recommended.
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MESH Headings
- Aged
- Anticoagulants/therapeutic use
- Craniocerebral Trauma/complications
- Craniotomy
- Disease Susceptibility
- Female
- Follow-Up Studies
- Functional Laterality/physiology
- Hematoma, Subdural/diagnostic imaging
- Hematoma, Subdural/epidemiology
- Hematoma, Subdural/surgery
- Hematoma, Subdural, Chronic/diagnostic imaging
- Hematoma, Subdural, Chronic/epidemiology
- Hematoma, Subdural, Chronic/surgery
- Humans
- India/epidemiology
- Male
- Middle Aged
- Nervous System Diseases/etiology
- Neurosurgical Procedures
- Postoperative Care
- Postoperative Complications/epidemiology
- Postoperative Complications/therapy
- Recurrence
- Retrospective Studies
- Tomography, X-Ray Computed
- Treatment Outcome
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Affiliation(s)
- Khursheed Nayil
- Department of Neurosurgery, Sher-i-Kashmir Institute of Medical Sciences, Kashmir, India.
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Neils DM, Singanallur PS, Wang H, Tracy P, Klopfenstein J, Dinh D, Elwood PW, Fassett D, McCall T, Lin J, Tsung A. Recurrence-free chronic subdural hematomas: a retrospective analysis of the instillation of tissue plasminogen activator in addition to twist drill or burr hole drainage in the treatment of chronic subdural hematomas. World Neurosurg 2011; 78:145-9. [PMID: 22120294 DOI: 10.1016/j.wneu.2011.08.032] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2011] [Revised: 05/25/2011] [Accepted: 08/30/2011] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To evaluate whether increasing the volume drained from chronic subdural hematomas (SDHs) via either twist drill drainage (TDD) or burr hole drainage (BHD) followed by instillation of tissue plasminogen activator (tPA) is more efficacious than simple drainage alone. METHODS Patients admitted over the course of 42 months (2007-2010) to a single institution for treatment of chronic SDH were retrospectively evaluated. RESULTS There were 139 patients treated for chronic SDH; 54 patients were treated with BHD alone, 3 were treated with tPA after BHD, 85 were treated with TDD alone, and 12 were treated with tPA after TDD. Follow-up examinations were performed 1 month after treatment in 13 of 15 patients treated with tPA and 93 of 124 patients treated without tPA. Patients treated with tPA had a significantly lower rate of recurrence than patients treated without tPA (P=0.041). Patients treated with BHD had a recurrence rate of 11.8%, whereas patients treated with BHD and tPA had 0% recurrence. Patients treated with TDD had a recurrence rate of 30%, whereas patients treated with TDD and tPA had 0% recurrence. Without tPA, BHD was found to be a significantly better treatment than TDD (P=0.016). Mean drainage for TDD with tPA was 427.33 mL. There were no complications related to the administration of tPA. CONCLUSIONS This study adds another therapeutic option for patients with chronic SDH requiring treatment. In this retrospective study, the addition of tPA increased the volume of hematoma drained and significantly reduced the incidence of recurrence requiring further intervention regardless of cranial access route. No complications occurred related directly or indirectly to the administration of tPA. Further study of this technique is warranted.
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Affiliation(s)
- David M Neils
- Illinois Neurological Institute, Department of Neurosurgery, University of Illinois College of Medicine at Peoria, Peoria, Illinois, USA.
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Klimo P, Matthews A, Lew SM, Zwienenberg-Lee M, Kaufman BA. Minicraniotomy versus bur holes for evacuation of chronic subdural collections in infants-a preliminary single-institution experience. J Neurosurg Pediatr 2011; 8:423-9. [PMID: 22044363 DOI: 10.3171/2011.8.peds1131] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Various surgical interventions have been described to evacuate chronic subdural collections (CSCs) of infancy. These include transfontanel percutaneous aspiration, subdural drains, placement of bur hole(s) with or without a subdural drain, and shunting. Shunt placement typically provides good long-term success (resolution of the subdural fluid), but comes with well-known early and late complications. Recently, the authors have used a mini-osteoplastic craniotomy technique with the goal of definitively treating these children with a single surgery while avoiding the many issues associated with a shunt. They describe their procedure and compare it with the traditional bur hole technique. METHODS In this single-institution retrospective study, the authors evaluated 26 cases involving patients who underwent treatment for CSC. Preoperative, intraoperative, and postoperative data were reviewed, including radiographic findings (density of the subdural fluid and ventricular and subarachnoid space size), neurological examination findings, and intraoperative fluid description. The primary outcome was treatment failure, defined as the patient requiring any subsequent surgical intervention after the index procedure (minicraniotomy or bur hole placement). RESULTS Fifteen patients (10 male and 5 female; median age 5.1 months) collectively underwent 27 minicraniotomy procedures (each procedure representing a hemisphere that was treated). In the bur hole group, there were 11 patients (6 male and 5 female; median age 4.6 months) with 18 hemispheres treated. Both groups had subdural drains placed. The average follow-up for each treatment group was just over 7 months. Treatment failure occurred in 2 patients (13%) in the minicraniotomy group compared with 5 patients (45%) in the bur hole group (p = 0.09). Furthermore, the 2 patients who had treatment failure in the minicraniotomy group required 1 subsequent surgery each, whereas the 5 in the bur hole group needed a total of 9 subsequent surgeries. Eventually, 80% of the patients in the minicraniotomy group and 70% of those in the bur hole group had resolution of the subdural collections on the last imaging study. CONCLUSIONS The minicraniotomy technique may be a superior technique for the treatment of CSCs in infants compared with bur hole evacuation. The minicraniotomy provides greater visualization of the subdural space and allows more aggressive evacuation of the fluid, better irrigation of the space, the ability to fenestrate any accessible membranes safely, and continued egress of fluid into the subgaleal space. Although this preliminary report has obvious limitations, evaluation of this technique may be worthy of a prospective, multiinstitutional collaborative effort.
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Affiliation(s)
- Paul Klimo
- Le Bonheur Children's Hospital, Memphis, Tennessee, USA
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A Randomized Controlled Trial Comparing the Outcome of Burr-Hole Irrigation with and without Drainage in the Treatment of Chronic Subdural Hematoma: A Preliminary Report. World Neurosurg 2011; 75:731-6; discussion 620-3. [DOI: 10.1016/j.wneu.2010.11.042] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2010] [Revised: 11/24/2010] [Accepted: 11/24/2010] [Indexed: 11/20/2022]
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Carlsen JG, Cortnum S, Sørensen JC. Recurrence of chronic subdural haematomata with and without post-operative drainage. Br J Neurosurg 2011; 25:388-90. [PMID: 21501053 DOI: 10.3109/02688697.2011.558945] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Chronic subdural haematoma is a common disease causing morbidity and mortality. Recurrence after surgical treatment is common, varying from 5% to 30% of cases. Several methods for reducing recurrence have been advocated. The aim of this study was to investigate the effect of post-operative subdural drainage. Three hundred forty-four patients were included in a retrospective study. Treatment was performed by burr hole irrigation. Groups were separated into those with post-operative drainage compared to those without. Recurrence occurred in 14% in the drained group, significantly less than 26% in the undrained group (p=0.011). There were no differences in the complication rates. Post-operative drainage reduces recurrence of chronic subdural haematoma without increasing the complication rate. These results support those reported in several other studies. We recommend the use of post-operative subdural drainage.
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Affiliation(s)
- Jakob G Carlsen
- Department of Neurosurgery, Aarhus University Hospital, Denmark.
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Amponsah K, Ellis TL, Chan MD, Bourland JD, Glazier SS, McMullen KP, Shaw EG, Tatter SB. Staged Gamma Knife Radiosurgery for Large Cerebral Arteriovenous Malformations. Stereotact Funct Neurosurg 2011; 89:365-71. [DOI: 10.1159/000329363] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2011] [Accepted: 05/04/2011] [Indexed: 11/19/2022]
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Lega BC, Danish SF, Malhotra NR, Sonnad SS, Stein SC. Choosing the best operation for chronic subdural hematoma: a decision analysis. J Neurosurg 2010; 113:615-21. [PMID: 19877806 DOI: 10.3171/2009.9.jns08825] [Citation(s) in RCA: 111] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Chronic subdural hematoma (CSDH), a condition much more common in the elderly, presents an increasing challenge as the population ages. Treatment strategies for CSDH include bur-hole craniostomy (BHC), twist-drill craniostomy (TDC), and craniotomy. Decision analysis was used to organize existing data and develop recommendations for effective treatment. METHODS A Medline search was used to identify articles about treatment of CSDH. Direct assessment by health care professionals of the relative health impact of common complications and recurrences was used to generate utility values for treatment outcomes. Monte Carlo simulation and sensitivity analyses allowed comparisons across treatment strategies. A second simulation examined whether intraoperative irrigation or postoperative drainage affect the outcomes following BHC. RESULTS On a scale from 0 to 1, the utility of BHC was found to be 0.9608, compared with 0.9202 for TDC (p = 0.001) and 0.9169 for craniotomy (p = 0.006). Sensitivity analysis confirmed the robustness of these values. Craniotomy yielded fewer recurrences, but more frequent and more serious complications than did BHC. There were no significant differences for BHC with or without irrigation or postoperative drainage. CONCLUSIONS Bur-hole craniostomy is the most efficient choice for surgical drainage of uncomplicated CSDH. Bur-hole craniostomy balances a low recurrence rate with a low incidence of highly morbid complications. Decision analysis provides statistical and empirical guidance in the absence of well-controlled large trials and despite a confusing range of previously reported morbidity and recurrence.
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Affiliation(s)
- Bradley C Lega
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.
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Yu GJ, Han CZ, Zhang M, Zhuang HT, Jiang YG. Prolonged drainage reduces the recurrence of chronic subdural hematoma. Br J Neurosurg 2010; 23:606-11. [PMID: 19922274 DOI: 10.3109/02688690903386983] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Recurrence of chronic subdural hematoma (CSH) is a significant problem in neurosurgical practice. Various risk factors associated with patient's characteristics and the pathogenesis of CSH have been investigated in many studies, but controversial findings are not uncommon. Therefore we made a retrospectively investigation focusing mainly on the factors associated with surgical techniques. in order to find out the factors that may affect the recurrence rate of CSH. The medical records of 97 consecutive patients with 121 CSHs, who were treated with burr-hole craniostomy and continuous drainage, were retrospectively reviewed. The relationships between the recurrence rate and some factors associated with surgery, such as location of burr-hole, thickness of residual hematoma, location of drainage catheter, intracapsular air postsurgery, duration of drainage were investigated. The average recurrence rate was 6.6% in this whole series. For patients with less than three days of drainage, the recurrence rate was 16.3%, whereas for those with 3 and more days of drainage, the recurrence rate was only 1.3%. The duration of drainage significantly related to recurrence rate. In addition, a higher recurrence rate seemed to be associated with more intracapsular air postsurgery, but it did not reach statistically significant level in this study. Prolonged duration of drainage did not increase the frequency of infection in this series. We found in this study that the duration of drainage play an important role in the treatment of CSH and 3 full days of drainage seems to be necessary, especially for patients of 60 years and over. We presumed that it takes at least 3 days of drainage for outer membrane of CSH to get the restoration of a normal balance between coagulation and fibrinolysis after surgery, which is necessary for termination of the vicious cycle and resolution of the hematoma.
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Affiliation(s)
- Guang Jie Yu
- Department of Neurosurgery, Qingdao Haici Hospital, P.R. China.
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Ibrahim I, Maarrawi J, Jouanneau E, Guenot M, Mertens P, Sindou M. Évacuation des hématomes sous-duraux chroniques par la technique du twist-drill. Résultats d’une étude randomisée prospective entre un drainage de 48heures et un drainage de 96heures. Neurochirurgie 2010; 56:23-7. [DOI: 10.1016/j.neuchi.2009.11.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2009] [Accepted: 10/14/2009] [Indexed: 11/24/2022]
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Abstract
This review will clarify the natural history of chronic subdural haematoma (SDH). Chronic SDH has dual origins, one from subdural hygromas (SDG) and the other from acute SDHs. It occurs only in patients with a suitable pre-morbid condition, i.e. sufficient potential subdural space (PSS). In unresolved SDGs, proliferation of dural border cells produces the neomembrane. Unresolved SDGs become chronic SDHs by repeated micro-haemorrhages from fragile new vessels, which were grown into the neomembrane. When PSS is sufficient, acute SDHs may become chronic SDHs. Chronic SDHs enlarge when rebleeding exceeds absorption and they become symptomatic. When the neomembrane is matured, the neocapillary is no longer fragile. If absorption exceeds rebleeding, the haematoma will disappear. Maturation of the neomembrane and stabilization of the neovasculature eventually result in spontaneous resolution. The fate of chronic SDH depends on the pre-morbid status, the dynamics of absorption-expansion and maturation of the neomembrane.
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Affiliation(s)
- K-S Lee
- Department of Neurosurgery, Soonchunhyang University Chonan Hospital, Chonan, Korea.
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Role of angiogenic growth factors and inflammatory cytokine on recurrence of chronic subdural hematoma. ACTA ACUST UNITED AC 2009; 71:161-5; discussion 165-6. [DOI: 10.1016/j.surneu.2008.01.023] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2007] [Accepted: 01/05/2008] [Indexed: 11/23/2022]
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