[Chronic subdural hematoma: study of 161 patients and the relationship with coagulation abnormalities]

The chronic subdural hematoma represents one of the most frequent types of intracranial hemorrhage. One hundred sixty one patients operated in the Clinical Hospital of State University of Campinas-SP (UNICAMP) from April 1994 to May 2000, were analyzed retrospectively in order to characterize the population and to study the importance of the pre-operative coagulation analysis in the outcome. The majority of the population was male (86%), white (85.1%) and in the fifth decade (median age: 57 years). A high mortality index in the postoperative period was found in patients with INR (international normalized ratio) values greater than 1.25 and/or thrombocytopenia (p<0.001 and p=0.004 respectively). Patients with previous head injury history (76%) showed a lower mortality (p=0.044). The results stand out the importance of the pre-operative evaluation with coagulation studies in order to correct possible abnormalities.

The level of circulating endothelial progenitor cells may be associated with the occurrence and recurrence of chronic subdural hematoma

OBJECTIVES

The onset of chronic subdural hematoma may be associated with direct or indirect minor injuries to the head or a poorly repaired vascular injury. Endothelial progenitor cells happen to be one of the key factors involved in hemostasis and vascular repair. This study was designed to observe the levels of endothelial progenitor cells, white blood cells, platelets, and other indicators in the peripheral blood of patients diagnosed with chronic subdural hematoma to determine the possible relationship between the endothelial progenitor cells and the occurrence, development, and outcomes of chronic subdural hematoma.

METHOD

We enrolled 30 patients with diagnosed chronic subdural hematoma by computer tomography scanning and operating procedure at Tianjin Medical University General Hospital from July 2009 to July 2011. Meanwhile, we collected 30 cases of peripheral blood samples from healthy volunteers over the age of 50. Approximately 2 ml of blood was taken from veins of the elbow to test the peripheral blood routine and coagulation function. The content of endothelial progenitor cells in peripheral blood mononuclear cells was determined by flow cytometry.

RESULTS

The level of endothelial progenitor cells in peripheral blood was significantly lower in preoperational patients with chronic subdural hematomas than in controls. There were no significant differences between the two groups regarding the blood routine and coagulation function. However, the levels of circulating endothelial progenitor cells were significantly different between the recurrent group and the non-recurrent group.

CONCLUSIONS

The level of circulating endothelial progenitor cells in chronic subdural hematoma patients was significantly lower than the level in healthy controls. Meanwhile, the level of endothelial progenitor cells in recurrent patients was significantly lower than the level in patients without recurrence. Endothelial progenitor cells may be related to the occurrence and recurrence of chronic subdural hematoma.

Aquaporin 2 in Cerebral Edema: Potential Prognostic Marker in Craniocerebral Injuries

Despite continuous medical advancements, traumatic brain injury (TBI) remains a leading cause of death and disability worldwide. Consequently, there is a pursuit for biomarkers that allow non-invasive monitoring of patients after cranial trauma, potentially improving clinical management and reducing complications and mortality. Aquaporins (AQPs), which are crucial for transmembrane water transport, may be significant in this context. This study included 48 patients, with 27 having acute (aSDH) and 21 having chronic subdural hematoma (cSDH). Blood plasma samples were collected from the participants at three intervals: the first sample before surgery, the second at 15 h, and the third at 30 h post-surgery. Plasma concentrations of AQP1, AQP2, AQP4, and AQP9 were determined using the sandwich ELISA technique. CT scans were performed on all patients pre- and post-surgery. Correlations between variables were examined using Spearman's nonparametric rank correlation coefficient. A strong correlation was found between aquaporin 2 levels and the volume of chronic subdural hematoma and midline shift. However, no significant link was found between aquaporin levels (AQP1, AQP2, AQP4, and AQP9) before and after surgery for acute subdural hematoma, nor for AQP1, AQP4, and AQP9 after surgery for chronic subdural hematoma. In the chronic SDH group, AQP2 plasma concentration negatively correlated with the midline shift measured before surgery (Spearman's ρ -0.54; p = 0.017) and positively with hematoma volume change between baseline and 30 h post-surgery (Spearman's ρ 0.627; p = 0.007). No statistically significant correlation was found between aquaporin plasma levels and hematoma volume for AQP1, AQP2, AQP4, and AQP9 in patients with acute SDH. There is a correlation between chronic subdural hematoma volume, measured radiologically, and serum AQP2 concentration, highlighting aquaporins' potential as clinical biomarkers.

The relationship between serum coagulation parameters and the recurrence of chronic subdural hematoma

The aim is to investigate the relationship between serum coagulation parameters (PT, APTT, D-D and FDP) before hospitalization and recurrence of chronic subdural hematoma (CSDH). 236 patients with CSDH who were diagnosed for the first time and had complete medical records were followed up for at least 90 days. Fifty patients (21.2%) had relapsed. Univariate analysis was conducted including general data, imaging data and test results. Serum coagulation parameters (PT, APTT, D-D and FDP) were detected for all CSDH patients. The study identified several factors that exhibited a significant correlation with chronic subdural hematoma (CSDH) recurrence. These factors included advanced age (p = 0.01), hypertension (p = 0.04), liver disease (p = 0.01), anticoagulant drug use (p = 0.01), antiplatelet drug use (p = 0.02), bilateral hematoma (p = 0.02), and single-layer hematoma (p = 0.01). In addition, the presence of fibrin/fibrinogen degradation products (FDP) exceeding 5 mg/L demonstrated a significant relationship with CSDH recurrence (P < 0.05). Notably, the combined assessment of D-dimer (D-D) and FDP exhibited a significant difference, particularly regarding recurrence within 30 days after surgery (P < 0.05). The simultaneous elevation of serum FDP and D-D levels upon admission represents a potentially novel predictor for CSDH recurrence. This finding is particularly relevant for patients who experience recurrence within 30 days following surgical intervention. Older individuals with CSDH who undergo trepanation and drainage should be closely monitored due to their relatively higher recurrence rate.

Evaluation of Peripheral Blood Inflammatory Markers in Patients with Chronic Subdural Hematoma

BACKGROUND AND AIM

Chronic subdural hematoma (CSH) refers to intracranial hemorrhages frequently caused by minor head trauma and is mostly seen in middle and advanced age. One of the hypotheses regarding the development of CSH is that the inflammatory cascade plays a pivotal role in this process.

MATERIALS AND METHODS

The inclusion criteria covered patients in all ages who were diagnosed as CSH by computed tomography and/or magnetic resonance imaging and treated by surgical intervention in our clinic between 2018 and 2020. Patient files were reviewed retrospectively, and medical records of age, gender, trauma history, unilateral or bilateral lesion, and leukocyte, neutrophil, lymphocyte, monocytes, and platelet counts were obtained. Receiver operating characteristic (ROC) analysis was used for the most appropriate neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), and age discrimination in the presence of CSH, and multiple logistic regression analyses were used to determine the effect of independent factors on dependent variables.

RESULTS

A total of 68 cases, 57 (83.8%) male and 11 (16.2%) female, aged between 13 and 93, were included in the study. The mean age of the patients included in the study was 72.59 ± 13.13 years. NLR of the cases ranged from 1.37 to 34.18, with a mean of 6.53 ± 6.74 and a median of 3.57. NLR and PLR were found to be statistically significantly higher in CSH patients compared to the healthy control group, and the cut-off values for NLR, PLR, and age were 2.8, 132, and 55, respectively. Age and NLR were found to be independent factors associated with CSH (P < 0.05).

CONCLUSION

As seen from the results of this study, peripheral blood values in CSH patients may be significantly higher than in the healthy control group, while they are below the normal laboratory cut-off values.

Possible role of cyclooxygenase-2 in developing chronic subdural hematoma

Inflammatory cytokines are reportedly involved in the pathogenesis of chronic subdural hematomas (CSH), and the angiogenesis of hematomas has particularly been in focus. Cyclooxygenase-2 (COX-2) is an essential enzyme for the synthesis of prostaglandin E2 (PGE2). The COX-2-PGE2 pathway has been shown to influence angiogenic factors such as vascular endothelial growth factor (VEGF). We investigated the association of COX-2 expression in the dura mater and outer membrane with the pathogenesis of CSH, and suggested a treatment strategy on the basis of this association. Hematoma fluid and serum samples obtained from 37 patients, and samples of the dura mater and outer CSH membrane obtained from 13 patients during the operation were examined in this study. The concentrations of PGE2 in relation to COX-2 in the hematoma fluid were significantly higher than those in the serum. Immunohistochemical analyses revealed COX-2-positive cells in the outer membrane of CSHs. There was a linear and significant relationship between PGE2 concentration in hematoma fluid and the interval from trauma to initial surgery. COX-2 may play a crucial role during the development of CSHs. Our study might lead to the development of anti-COX-2 treatment options that aim to minimize repeat surgery and choose medical therapy by reducing CSH morbidity and recurrence rate in patients with CSH.

Metabolomic markers of electrolytes, gases and internal environment of the content of chronic subdural hematomas

BACKGROUND AND OBJECTIVE

Chronic subdural hematoma is one of the most common diseases in neurosurgical practice. The content of electrolytes and gases in the collection could participate in the growth and expansion mechanism, however, there is no evidence that they have been studied before. The objective has been to identify electrolyte, gas and internal metabolomic markers of the content of chronic subdural hematomas, with the possibility of participating in their growth and expansion and to substantiate a pathophysiological hypothesis that interacts with existing ones.

MATERIAL AND METHOD

A descriptive study was carried out with 53 patients operated on for chronic subdural hematoma, at the "Roberto Rodríguez Fernández" General Teaching Hospital of Morón in Ciego de Ávila, Cuba, in the period between January 2019 and December 2023. The diagnoses were obtained with computed axial tomography. The electrolyte and blood gas components of hematomas are correlated with clinical and neuroimaging variables.

RESULTS

Patients over 70 years of age predominated, 37 (69.81%) and males 38 (71.70%). The Markwalder scale upon admission showed a predominance of Grade III in 24 cases (45.28%). The Glasgow outcome scale showed a predominance of Grade V, 31 (58.49%).

CONCLUSIONS

Electrolyte and gasometric metabolomic markers of subdural blood can promote the phenomenon of progressive growth and expansion and have a synergistic effect with the rest of the pathophysiological mechanisms.

[Physiopathology of chronic subdural hematoma]

Coagulation, fibrinolysis and kinin-kallicrein system disorders could explain chronic subdural hematoma pathophysiology. The marked decrease in antithrombin III in the hematoma suggest that the decreased levels of clotting factors were caused by excessive coagulation resulting in clotting factors consumption. The decrease in alpha 2-antiplasmin with the increase of fibrin degradation products suggest that hyperfibrinolytic activity of the subdural hematoma. Coagulation and fibrinolysis disorders could explain repetitive hemorrhages from the outer membrane, which cause progressive enlargement of the hematoma. Kinin-kallicrein system disorders raise the hemorrhage by its action on the outer membrane. Nowadays, the earliest osmotic theory should reasonably be abandoned.

[Relationship between classification of CSDH according to the Internal architecture and hematoma contents]

BACKGROUND

Based on the finding of temporal changes in the internal architecture on CT scans, we classified CSDH into 4 types: the homogeneous type, the laminar type, the separated type, and the trabecular type. The purpose of this study was to statistically analyze the relationship between the type of CSDH and the hematoma contents.

METHODS

This study assessed 45 consecutive CSDH patients. All of them were assigned to our 4 types of CT classification of CSDH, and the counts of blood cells including WBC, RBC, Hb, Ht, and platelets, as well as FDP and fibrinogen levels in the hematoma and peripheral venous blood were examined.

RESULTS

The mean RBC count was 345.3 (SD = 177.9) in all the subjects versus 426.4 (SD = 165.6) in Hm, 408.3 (SD = 79.2) in Lm, 357.2 (SD = 298.7) in Sp, and 200.0 (SD = 129.2) in Tr. The mean Hb concentration was 10.2 (SD = 5.2) in all the subjects versus 12.9 (SD = 5.3) in Hm, 12.3 (SD = 2.7) in Lm, 9.2 (SD = 6.5) in Sp, and 5.9 (SD = 4.2) in Tr. The eosinophil and lymphocyte counts were high in all the types (15.0% and 48.4% on average). The FDP concentration was high in all patients (500-5,000). Fibrinogen levels were less than 10 in all hematoma types. CRP was an average of 3.1 (SD = 4.9) in all the subjects versus 7.5 (SD = 9.8) in Hm, 2.5 (SD = 1.6) in Lm, 3.0 (SD = 2.9) in Sp, and 1.1 (SD = 1.6) in Tb.

CONCLUSION

There were relationships between the type of CSDH and the RBC, Hb, Ht, and CRP values.