Abstract
Objective: The surgical technique, safety, efficacy, and clinical application value of the intra-neuroendoscopic technique (INET) for the treatment of subacute-chronic and chronic septal subdural hematoma was investigated based on the structure and pathological features of the hematoma wall, and the critical factors of hematoma growth and recurrence were determined, in order to provide reference for clinical drug treatment.Methods: This was non-randomized concurrent control study. A total of 94 patients who met the inclusion criteria were recruited between May 2015 and February 2019 and were divided into the INET treatment group (INET group, 45 cases) and the burr hole drainage (BHD) treatment group (control group, 49 cases). The hematoma fluid components and the morphological structure and pathological characteristics of the hematoma wall were analyzed, and the surgical duration, subdural drainage tube (SDT) placement duration, intracranial infection rate, Bender grade at the 1 month post-operative follow-up and hematoma recurrence rate within the 6 months of post-operative follow-up were compared between the two groups. A multiple logistic regression model was established to analyze the risk factors associated with recurrence within 6 months.Results: Intraoperative endoscopy showed that the adhesion bands that formed early in the hematoma cavity were strip-like and that those that formed late were lock-column-like. The hematoma cavity was divided into different-sized chambers with by these strips/columns. Pathological sections of cyst wall reveled angiogenesis inside the cyst and mucus-like changes, rupture and hemorrhage in the vascular wall. Obvious inflammatory cell infiltration and fibrous connective tissue hyperplasia were observed in the cyst wall. The osmotic pressure of the hematoma fluid was not significantly different from that of the peripheral venous blood [(296.7 ± 10.3) mOsm/kg vs. (291.5 ± 12.4) mOsm/kg, p = 0.68]. However, the D-dimer contents which reflect the severity of fibrinolysis in the hematoma and the proinflammatory cytokine interleukin 6 (IL-6) were significantly higher in the hematoma fluid than in the peripheral venous blood. The surgery duration for the INET group was significantly longer than that for the control group [(60.4 ± 10.6) min vs. (44.1 ± 9.8) min, p = 0.00], but both the hematoma recurrence rate within 6 months of post-operative follow-up (4.4 vs. 24.5%, p = 0.00) and the SDT placement duration [(2.1 ± 0.6) d vs. (3.9 ± 0.7) d, p = 0.00] for the INET group were both lower than those for the control group. The intracranial infection rate did not differ significantly between the two groups (4.4 vs. 10.2%, p = 0.50). The overall effective rate of the Bender grade at 1 month of follow-up did not differ significantly between the two groups (95.6 vs. 87.8%, p = 0.32), but the proportion of patients who recovered to Bender grade 0 with no symptoms was significantly higher in the INET group than in the control group (86.7 vs. 67.3%, p = 0.03). Multiple logistic regression analysis showed that INET surgery [odds ratio (OR) 3.71, 95% confidence interval (CI) 1.31–9.62, p = 0.02], age of 65 years or younger (OR 1.51, 95% CI 1.05–2.87, p = 0.03) and unilateral subdural hematoma (OR 1.76, 95% CI 1.05–3.41, p = 0.02) were independent factors that reduced the post-operative recurrence rate.Conclusion: The INET surgical plan based on the structure and pathological features of the subacute-chronic and chronic subdural hematoma wall can reduce the recurrence rate and improve the clinical prognosis.Trial registration: ClinicalTrials.gov, NCT02515903. Registered 5 August, 2015.
Highlights
Chronic subdural hematoma often affects middle-aged and elderly individuals with a history of minor trauma and is a common intracranial hemorrhagic disease, accounting for approximately 10% of all intracranial hematomas
Logistic regression analysis showed that intra-neuroendoscopic technique (INET) surgery [odds ratio (OR) 3.71, 95% confidence interval (CI) 1.31–9.62, p = 0.02], age of 65 years or younger and unilateral subdural hematoma were independent factors that reduced the post-operative recurrence rate (Table 4)
Our study found that the structural characteristics of the Chronic subdural hematoma (cSDH) cavity are as follows: [1] The bleeding site inside the hematoma cavity is often at the wall layer, especially at the fold between the wall layer and the visceral layer close to the dura mater, and the main root of the fiber strip or column is at the wall layer
Summary
Chronic subdural hematoma (cSDH) often affects middle-aged and elderly individuals with a history of minor trauma and is a common intracranial hemorrhagic disease, accounting for approximately 10% of all intracranial hematomas. The recurrence rate of hematoma after different surgeries in patients with cSDH is 2.3–38.7% [3, 5,6,7,8]. The rate of patients requiring reoperation due to post-operative recurrence is as high as 31.6% [3]. Subacute-chronic and chronic septal subdural hematomas are complicated cSDH types with high post-operative recurrence rates. Based on the structure and pathological features of the subacute-chronic and chronic septal subdural hematoma wall, the intra-neuroendoscopic technique (INET) was performed in this non-randomized concurrent control study (classic BHD was the control treatment), and the surgical technique, safety, efficacy, and clinical value of INET for the treatment of these diseases were investigated. The key factors of hematoma growth and recurrence were analyzed through clinical and pathological examinations, aiming to provide a reference for the clinical treatment of cSDH
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