Burr hole surgery for acute subdural hematoma with recombinant tissue-type plasminogen activator injected into hematoma cavity: two-patient case report

The rationale of performing surgery for acute subdural hematoma (ASDH) to reduce mortality is often compared with the self-evident effectiveness of a parachute when skydiving. Nevertheless, it is of clinical relevance to estimate the magnitude of the effectiveness of surgery. The aim of this study is to determine whether surgery reduces mortality in traumatic ASDH compared with initial conservative treatment. A systematic search was performed in the databases IndexCAT, PubMed, Embase, Web of Science, Cochrane library, CENTRAL, Academic Search Premier, Google Scholar, ScienceDirect, and CINAHL for studies investigating ASDH treated conservatively and surgically, without restriction to publication date, describing the mortality. Cohort studies or trials with at least five patients with ASDH, clearly describing surgical, conservative treatment, or both, with the mortality at discharge, reported in English or Dutch, were eligible. The search yielded 2025 reports of which 282 were considered for full-text review. After risk of bias assessment, we included 102 studies comprising 12,287 patients. The data were synthesized using meta-analysis of absolute risks; this was conducted in random-effects models, with dramatic effect estimation in subgroups. Overall mortality in surgically treated ASDH is 48% (95% confidence interval [CI] 44-53%). Mortality after surgery for comatose patients (Glasgow Coma Scale ≤8) is 41% (95% CI 31-51%) in contemporary series (after 2000). Mortality after surgery for non-comatose ASDH is 12% (95% CI 4-23%). Conservative treatment is associated with an overall mortality of 35% (95% CI 22-48%) and 81% (95% CI 56-98%) when restricting to comatose patients. The absolute risk reduction is 40% (95% CI 35-45%), with a number needed to treat of 2.5 (95% CI 2.2-2.9) to prevent one death in comatose ASDH. Thus, surgery is effective to reduce mortality among comatose patients with ASDH. The magnitude of the effect is large, although the effect size may not be sufficient to overcome any bias.

To analyze the reasons and patient-related and injury-related risk factors for reoperation after surgery for acute subdural hematoma (SDH) and the effects of reoperation on treatment outcome. Among adult patients operated on for acute SDH between 2013 and 2017, patients reoperated within 14 days after the primary surgery were identified. In all patients, parameters were identified that related to the patient (age, anticoagulation, antiplatelet, and antiepileptic treatment, and alcohol intoxication), trauma (Glasgow Coma Score, SDH thickness, midline shift, midline shift /hematoma thickness rate, other surgical lesion, primary surgery-trephination, craniotomy, or decompressive craniotomy), and Glasgow Outcome Score (GOS). The reasons for reoperation and intervals between primary surgery and reoperation were studied. Of 86 investigated patients, 24 patients were reoperated (27.9%), with a median interval of 2 days between primary surgery and reoperation. No significant differences in patients and injury-related factors were found between reoperated and non-reoperated patients. The rate of primary craniectomies was higher in non-reoperated patients (P = 0.066). The main indications for reoperation were recurrent /significant residual SDH (10 patients), contralateral SDH (5 patients), and expansive intracerebral hematoma or contusion (5 patients). The final median GOS was 3 in non-reoperated and 1.5 in reoperated patients, with good outcomes in 41.2% of non-reoperated and 16.7% of reoperated patients. Reoperation after acute SDH surgery is associated with a significantly worse prognosis. Recurrent /significant residual SDH and contralateral SDH are the most frequently found reasons for reoperation. None of the analyzed parameters were significant reoperation predictors.

Three types of surgical treatment and adjunctive barbiturate therapy were evaluated by analyzing their outcome in patients with traumatic acute subdural hematoma. From June, 1982 to December, 1990, 120 patients underwent surgery for acute subdural hematoma at Kurume University Hospital. Of these, 108 patients admitted to the hospital with a Glasgow Come Scale (GCS) score of 8 or less, and 75 with a GCS score of 5 or less. Removal of the hematoma with craniotomy (RH), removal of the hematoma with decompressive hemicraniectomy (DH) and hematoma irrigation with trephination therapy (HITT) were performed in 42, 51 and 27 patients, respectively. Of those with uncontrolled intracranial pressure over 30 mmHg, 23 were treated with barbiturates. The overall mortality rate was 51.7%, and the rate of good outcome was 26.7%. The rate of good outcome was singnificantly higher in the patients who underwent RH (47.6%), although the mortality rate of them was higher than that of the patients who underwent DH when the GCS score was 5 or less. Among the patients with a GCS score of 8 or less, the mortality rate was significantly higher in those who underwent HITT (74.1%). In patients with barbiturate therapy, RH had the best result. This study suggests that RH is preferable for acute subdural hematoma, although DH appears to be better for improving the mortality rate. HITT is not recommended in patients with a GCS score of 8 or less.

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.

Endoscopic hematoma evacuation following emergent burr hole surgery for acute subdural hematoma in critical conditions: Technical note

Objective: In the elderly population, subdural hematoma represents a significant cause of morbidity and mortality. The surgical and anesthesia techniques for managing this condition have progressively evolved. Unlike numerous studies that compare chronic cases managed under general anesthesia and sedation, our study uniquely focuses on acute subdural hematoma cases. Material and Method: From 2020 to 2024, a retrospective study reviewed 54 patients aged 65 and older who underwent surgery for acute subdural hematoma. The patients were categorized into two groups: sedation (n=26) and general anesthesia (n=28). Data on surgical duration, hospital and intensive care unit stays, and mortality rates were collected from hospital archives. The general anesthesia group received midazolam, fentanyl, propofol, and rocuronium, while the sedation group received midazolam, fentanyl, and propofol. Subdural drains were universally placed and removed after postoperative brain computed tomography. Results: The mortality rate was significantly lower in the sedation group compared to the general anesthesia group (p=0.024). Surgical duration was shorter in the sedation group (p

New traumatic brain contusions or worsening (or recurrent) subdural or epidural hematomas are examples of urgent neurosurgical indications. We describe the clinical course of a patient with a traumatic subdural hematoma followed by an opposite epidural hematoma after its evacuation. Surgery for acute subdural hematoma is considered when thickness of the subdural hematoma exceeds 1 cm or midline shift exceeds 5 mm on CT scan. The decision to operate remains arbitrary, but any patient with neurologic deterioration requires neurosurgical intervention. Surgical indications, early prediction of surgical outcome and the common postoperative seizure and EEG abnormalities are discussed. Postoperative neurocritical care in these patients is a core skill of neurointensivists.

Objective:We sought to determine 30-day survival trends and prognostic factors following surgery for acute subdural hematomas (ASDHs) in England and Wales over a 20-year period.Summary of Background Data:ASDHs are still considered the most lethal type of traumatic brain injury. It remains unclear whether the adjusted odds of survival have improved significantly over time.Methods:Using the Trauma Audit and Research Network (TARN) database, we analyzed ASDH cases in the adult population (>16 yrs) treated surgically between 1994 and 2013. Two thousand four hundred ninety-eight eligible cases were identified. Univariable and multiple logistic regression analyses were performed, using multiple imputation for missing data.Results:The cohort was 74% male with a median age of 48.9 years. Over half of patients were comatose at presentation (53%). Mechanism of injury was due to a fall (<2 m 34%, >2 m 24%), road traffic collision (25%), and other (17%). Thirty-six per cent of patients presented with polytrauma. Gross survival increased from 59% in 1994 to 1998 to 73% in 2009 to 2013. Under multivariable analysis, variables independently associated with survival were year of injury, Glasgow Coma Scale, Injury Severity Score, age, and pupil reactivity. The time interval from injury to craniotomy and direct admission to a neurosurgical unit were not found to be significant prognostic factors.Conclusions:A significant improvement in survival over the last 20 years was observed after controlling for multiple prognostic factors. Prospective trials and cohort studies are expected to elucidate the distribution of functional outcome in survivors.

Acute subdural hematomas (ASDH) are found frequently following traumatic brain injury (TBI) and they are considered the most lethal type of mass lesions. The decision to perform a procedure to evacuate ASDH and the approach, either via craniotomy or decompressive craniectomy (DC), remains controversial. We reviewed a prospectively collected series of 343 moderate to severe TBI patients in whom ASDH was the main lesion (ASDH volumes ≥10 cc). Patients with early comfort measures (early mortality prediction >50% and not ICP monitored), bilateral ASDH or the presence of another intracranial hematoma with volumes exceeding two times the volume of the ASDH were excluded. Among them, 112 were managed conservatively, 65 underwent ASDH evacuation by craniotomy and 166 by DC (103 pre-emptive DC, 63 obligatory DC). We calculated the average treatment effect by propensity score (PS) analysis using the following covariates: age, year, hypoxia, shock, pupils, major extracranial injury, motor score, midline shift, ASDH volume, swelling, intraventricular and subarachnoid hemorrhage presence. Then, multivariable binary regression and ordinal logistic regression analysis were performed to estimate associations between predictors and mortality and 12 months-GOS respectively. The patients' inverse probability weights were included as an independent variable in both regression models. The main variables associated with outcome were year, age, falls from patient´s own height, hypoxia, early deterioration, pupillary abnormalities, basal cistern effacement, compliance to ICP monitoring guidelines and type of surgical approach (craniotomy and pre-emptive DC). According to sliding dichotomy analysis, we found that patients in the intermediate or worst bands of unfavorable outcome prognosis seemed to achieve better than expected outcome if they underwent pre-emptive DC rather than craniotomy.

Introduction and importanceSubdural empyema (SE) following chronic subdural hematoma (CSDH) surgery is an uncommon but serious complication. The best treatment approach, typically a choice between craniotomy and burr hole surgery, is still debated. This case report introduces an innovative method using burr hole surgery with double-tube irrigation, a potentially effective alternative to the more invasive craniotomy. Case presentationAn 81-year-old male, 48 days post-CSDH surgery, developed SE with Methicillin-resistant Staphylococcus aureus infection. The initial treatment with burr hole drainage was complicated by recurrence, leading to a second procedure with double tubes inserted anteriorly and posteriorly for continuous irrigation therapy. The patient was treated with systemic antibiotics and vancomycin irrigation, resulting in successful resolution without further recurrence. Clinical discussionWhile burr hole surgery is often deemed less effective than craniotomy for SE, this case demonstrates the potential efficacy of double-tube irrigation via burr hole surgery. This method could be especially beneficial when craniotomy poses significant risks. Continuous irrigation could help in managing intracranial pressure, making the intervention safer. However, further research is needed to refine this technique and establish clear treatment guidelines. ConclusionBurr hole surgery with double-tube irrigation emerges as a promising treatment option for SE, especially when craniotomy is not feasible. This approach's success in this case encourages further exploration and study to validate its wider application in similar clinical scenarios.

While some patients require immediate surgery for acute subdural hematoma (ASDH), others can be managed conservatively. A subset of patients, however, may experience the progression of ASDH to a relevant chronic subdural hematoma (CSDH). This systematic review aims to synthesize studies focusing on ASDH which progress to CSDH. We searched relevant databases for articles. Six issues were addressed: Which percentage of conservatively managed ASDH progressed to CSDH requiring treatment? What were possible risk factors for this progression? How long was the time span for chronification? How did the clinical status change during chronification? How did the radiographic parameters change during chronification? How was this entity surgically treated? Fourteen studies met the inclusion criteria. The proportion of conservatively managed ASDH patients who eventually required surgery due to CSDH ranged from 6.5% to 45.3%. Several risk factors for progression were identified, with initial hematoma size and midline shift being the most significant. The majority required surgery within two to three weeks following trauma. As ASDH progressed to CSDH, a notable deterioration in clinical status occurred for many patients, including a decline in consciousness. While the hematoma density decreased, its size and midline shift increased. Most patients underwent burr hole trephination. The progression of ASDH to CSDH often led to an increase in hematoma size and midline shift, resulting in the worsening of clinical symptoms. Surgery was typically required within the second or third week after trauma for these patients.

Functional Outcomes After Surgery for Acute Subdural Hematoma: A Comparison Between Decompressive Craniectomy Versus Craniotomy in Post-Traumatic Patients

Background: Acute subdural hematoma (ASDH) is a common disease and craniotomy is the first choice for removing hematoma. However, patients for whom craniotomy or general anesthesia is contraindicated are increasing due to population aging. In our department, we perform burr hole surgery under local anesthesia with urokinase administration for such patients. We compared the patient background and outcomes between burr hole surgery and craniotomy to investigate the surgical safety criteria for burr hole surgery.Methods: We reviewed 24 patients who underwent burr hole surgery and 33 patients who underwent craniotomy between January 2010 and April 2020 retrospectively.Results: The median age of the burr hole surgery group was older (P = 0.01) and they had multiple pre-existing conditions. Compared with the craniotomy group, neurological deficits and CT findings were minor in the burr hole surgery group, whereas the maximum hematoma thickness was not significantly different. The hematoma was excreted after a total of 54,000 IU of urokinase was administered for a median of 3 days. The Glasgow Coma Scale score improved in all patients in the burr hole surgery group and there were no deaths. Age, especially over 65 y.o., (OR 1.16, 95% CI 1.04–1.30) and the absence of basal cistern disappearance (OR 0.04, 95% CI 0.004–0.39) were significant factors.Conclusion: Burr hole surgery was performed safely in all patients based on the age, especially older than 65 y.o., and the absence of basal cistern disappearance. ASDH in the elderly is increasing and less invasive burr hole surgery with urokinase is suitable for the super-aging society.

Adjuvant medical treatment to reduce the recurrence rate after burr hole surgery for chronic subdural hematoma (CSDH) has not yet been established. This study aimed to investigate the association between tranexamic acid (TXA) use after burr hole surgery and the reoperation rate in patients with CSDH. This observational study used the Japanese Diagnostic Procedure Combination inpatient database, a nationwide inpatient database in Japan, from July 1, 2010, to March 31, 2019. The authors identified patients who were hospitalized for CSDH and underwent burr hole surgery within 2 days of admission. The primary outcome measure was reoperation within 1 year after surgery. One-to-one propensity score-matched analysis was performed to compare the outcomes between patients who started oral TXA within 2 days after surgery (TXA users) and those who did not (TXA nonusers). Robustness of the analyses was assessed using the instrumental variable analysis. Of the 149,543 patients with CSDH treated at 1100 hospitals, 7366 (4.9%) were TXA users. Propensity score matching created 6564 matched pairs with highly balanced baseline characteristics. The reoperation rate was significantly lower in TXA users than in nonusers (1.9% vs 6.1%, p < 0.001) with a risk difference of -4.1% (95% CI -4.8% to -3.4%). There was no significant difference in composite adverse events (0.6% vs 0.5%, p = 0.817). Total hospitalization costs were also significantly lower in TXA users than in nonusers ($5229 vs $5344 [USD], p < 0.001). The results of the instrumental variable analysis were consistent with those of the propensity score-matched analysis. Findings of this study, using a nationwide inpatient database, suggest that adjuvant TXA use after burr hole surgery was associated with a reduced reoperation rate in patients with CSDH.

Loss to follow-up (LTF) and unplanned readmission are barriers to recovery after acute subdural hematoma evacuation. The variables associated with these postdischarge events are not fully understood. To determine factors associated with LTF and unplanned readmission, emphasizing socioeconomic status (SES). A retrospective analysis was conducted of surgical patients with acute subdural hematoma managed operatively from 2009 to 2019 at a level 1 regional trauma center. Area Deprivation Index (ADI), which is a neighborhood-level composite socioeconomic score, was used to measure SES. Higher ADI corresponds to lower SES. To decrease the number of covariates in the model, principal components (PCs) analysis was used. Multivariable logistic regression analyses of PCs were performed for LTF and unplanned readmission. A total of 172 patients were included in this study. Thirty-six patients (21%) were LTF, and 49 (28%) patients were readmitted; 11 (6%) patients were both LTF and readmitted ( P = .9). The median time to readmission was 10 days (Q1: 4.5, Q3: 35). In multivariable logistic regression analyses for LTF, increased ADI and distance to hospital through PC2 (odds ratio [OR] 1.49; P = .009) and uninsured/Medicaid status and increased length of stay through PC4 (OR 1.73; P = .015) significantly contributed to the risk of LTF. Unfavorable discharge functional status and nonhome disposition through PC3 were associated with decreased odds of unplanned readmission (OR = 0.69; P = .028). Patients at high risk for LTF and unplanned readmissions, as identified in this study, may benefit from targeted resources individualized to their needs to address barrier to follow-up and to ensure continuity of care.