Chronic Subdural Hematoma (CSDH) score for predicting outcome in CSDH in a tertiary care center in Nepal

Objective: Chronic subdural hematoma (C-SDH) is a common disease clinically. Nearly all patient have unilateral C-SDH, but bilateral C-SDH is not rare. We thought that there are the differences in clinical characteristics between unilateral and bilateral C-SDH even though we have good results through the simple burr hole drainage. The authors analyzed the clinical feature of unilateral and bilateral C-SDH. Materials and Methods: Sixty seven C-SDH patients were included who were operated on burrhole trephination and closed system drainage between January, 1996 and December, 2005 in our hospital. The patents were divided 28 bilateral C-SDH patients (Group A) and 39 unilateral C-SDH patients (Group B). We analyzed etiology, co-existing disease, neurologic status at admission, radiologic hematoma thickness, drainage duration and amount after operation, postoperative complication, recurrence, neurologic status at discharge between two groups. Results: We have more male patients than female patients in both groups. Trauma is major etiology in two groups. The most of causes in hemorrhage are correlated with chronic medical diseases, but there is no difference at co-existing disease between two groups. At radiologic features, one side hematoma thickness in bilateral hematoma groups was thiner than that in unilateral hematoma groups. But, the sum of bilateral hematoma thickness is no difference of unilateral hematoma thickness. Drainage amount of hematoma is more in bilateral C-SDH, but there is no statistical difference. Recurrence rate is more in unilateral hematoma (10%) than in bilateral hematoma (4%). The good outcome is attained in Glasgow outcome scale (GOS) at discharge in both groups. Conclusion: Bilateral hematoma patients had more coexisting disease, had more longer duration between symptom development and operation, and also more drainage amount of hematoma. Drainage amount would be correlated with preoperative clinical severity in this study. If there was more drainage amount of hematoma, there was more worse clinical outcome. In bilateral hematoma patients, clinical symptom was more worse than unilateral hematoma patients. Although bilateral chronic subdural hematoma patient would show worse clinical symptoms preoperatively, the postoperative results was as good as unilateral hematoma patient. The authors thought that we will improve the prognosis of bilateral C-SDH patients with poor neurologic symptom through rapid diagnosis and operation.

: Chronic subdural hematoma (CSDH) is a relatively frequent problem in neurologic or neurosurgical practice. Although CSDH is a well-known disease, data on bilateral CSDH are scarce compared with data on unilateral CSDH. The purpose of this study was to compare the clinical presentations, precipitating factors, computed tomography (CT) scan findings, postoperative complications, and outcomes between patients with bilateral and unilateral CSDH. : A retrospective study was performed on 129 surgical patients with CSDH from January 2002 to January 2005. These patients were divided into two groups: bilateral CSDH (45 cases) and unilateral CSDH (84 cases). Clinical presentations, precipitating factors, CT scan findings, postoperative complications, and outcomes of patients were analyzed. : The mean age was 75 years for patients with bilateral CSDH and was 68 years for patients with unilateral CSDH (p = 0.696). Males predominated in each group (p = 0.696). The frequency of presenting symptoms of nausea and vomiting, headache, or unsteady gait was significantly greater in bilateral CSDH than in unilateral CSDH (p < 0.05). The incidence of usage of anticoagulant and antiplatelet therapy was significantly higher in bilateral CSDH group than in unilateral CSDH group (p < 0.05). The frequency of marked midline shift on CT scans was significantly greater in unilateral CSDH than in bilateral CSDH (p < 0.05). Coexisting systemic diseases, postoperative complications, and outcomes had no significant differences between both groups. : Bilateral CSDH tended to occur more in patients with anticoagulant or antiplatelet therapy. Compared with patients with unilateral CSDH, patients with bilateral CSDH had more symptoms of increased intracranial pressure and lower incidences of midline shift on CT scans. Most patients with either bilateral or unilateral CSDH had a good postoperative outcome.

Introduction: The relationships between Glasgow Outcome Scale (GOS), Glasgow Coma Scale (GCS) and brain computerized tomography (CT) with unilateral chronic subdural hematoma (CSDH) are not consistent in studies. Methods: Between Oct 2005 to March 2009, 93 unilateral CSDH patients (mean age 71±11 years) were enrolled for analysis. The associations between GOS at discharge and the following variables on admission including sex, age, GCS, time interval from injury to emergency room, hematoma site, hematoma thickness, hematoma density, midline shift, ventricular sizes (Evan's index and maximum diameter of third ventricle-3Vmax. D), and cortical atrophy on brain CT were evaluated. Results: By multiple logistic regression statistics, the adjusted odds ratio (OR) in predicting the poor outcome was significant with GCS ＜15 [OR=11.2, CI=1.3-96.9, p=0.028] and mixed density hematoma on brain CT [OR=7.4, CI=1.8-31.7, p=0.007]. Using Receiver-Operating Characteristic (ROC) curve, the sensitivity was 73% and the specificity was 85%. Conclusions: In our preliminary study that mixed hematoma density and lower GCS were associated with poor prognosis in unilateral CSDH with sensitive prediction.

Introduction: Urolithiasis is common in the pediatric population in low-resource countries but appropriate management is not available in all parts of the country. This study aimed to identify demographic parameters, clinical characteristics, and surgical management of pediatric urolithiasis in a tertiary care center in Nepal. Methods: This was a retrospective and descriptive study of pediatric patients (≤18 years) who underwent surgical management of urolithiasis in the Department of Urology and Kidney Transplant Surgery, Tribhuvan University Teaching Hospital from January 2021 to December 2022. Results: Total 64 patients with Male: Female ratio 1.78:1 and mean age of 8.63±5.56 years presented mostly with pain abdomen (93.8%) followed by lower urinary tract symptoms (26.6%), hematuria (20.3%), and fever (14.1%). The mean number of calculi was 2.2±1.47 and the mean size was 13.97±8.30 mm. Most of the calculi (39.1%) were in the right system and 90.62% were in the upper tract. Only 15.62% of patients had calculi in the lower tract. Open surgeries were performed in only 10.93% and the rest were managed by minimally invasive procedures. Percutaneous nephrostomy tube insertion was done in 6 (9.37%) of patients and 1 (1.56%) underwent nephrectomy for nonfunctioning kidney. Conclusion: Pediatric urolithiasis patients presented with pain abdomen, lower urinary tract symptoms, or hematuria. Surgical management has shifted from open surgeries in the past to minimally invasive surgeries at present.

Chronic subdural hematoma (CSDH) has been recognized as a benign disease, but its clinical outcome is not well documented. This study aims to expand the knowledge base regarding the outcome of CSDH. We retrospectively reviewed clinical characteristics of CSDH operated in the Kobe City Medical Center General Hospital between June 2005 and June 2012. Variants included age at onset, sex, laterality, presence of headache, consciousness level, and risk factors for hemorrhage such as malignancy or intake of anticoagulants. A total of 368 cases were analyzed. Six patients (1.4%) had a poor outcome, defined as any morbidity or mortality at 7 days postoperatively. Bilateral hematoma was significantly associated with a poor outcome (p = 0.041). Warfarin use and malignancy, albeit statistically not significant, were more frequently observed in patients with a poor outcome. Bilateral CSDH was observed in 53 patients (14.4%). Age at onset, sex, history of malignancy, anticoagulant use, and antiplatelet use did not differ between bilateral and unilateral CSDH. Recurrence rate was not different between bilateral and unilateral CSDH (14.2% vs. 11.3%), but poor outcome as a result of brain herniation was significantly higher in bilateral than in unilateral hematomas (5.7% vs. 0.3%, p = 0.01). Bilateral CSDH was associated with rapid progression and showed worse outcome as a result of brain herniation in comparison with unilateral CSDH. Urgent trephination surgery for decompression of hematoma pressure may be recommended for bilateral CSDH.

Background Chronic subdural hematoma (CSDH) is predominantly a disease of the elderly.Objectives This article studies the clinical and radiological outcomes in patients with CSDH who had undergone bedside percutaneous twist drill craniostomy (TDC).Patients and Methods A retrospective study was conducted in 80 patients who had undergone percutaneous TDC for CSDH between January 2017 and December 2018. Patients between 18 and 90 years of age were selected. CSDH showing computed tomography (CT) scan findings of homogeneous hypodensity, homogeneous isodensity, mixed density, and CSDH with hyperdense gravity-dependent fluid level were selected. CT evidence of multiple septations, recurrent CSDH, bilateral CSDH, and acute on CSDH were excluded. The presence of midline shift (MLS) was measured as any deviation of the septum pellucidum from the midline. The mass effect was determined by the effacement of the sulci, Sylvian fissure obscuration, or compression of lateral ventricles. Postoperative decrease in the signs and symptoms were considered as the postoperative clinical improvement. Improvement in the postoperative CT scan was determined by the decrease in the thickness of CSDH and absence of MLS with decrease in the mass effect. The presence of the CSDH with mass effect and MLS was considered as the significant residue in the postoperative CT scan.Statistical Analysis Statistical analysis is done using Epi Info software.Results The mean age range was 67.78 years ± 12.03 standard deviation (SD). There were 49 (61.25%) males and 31 (38.75%) females. Thirty-eight (47.5%) CSDHs were on the right side and 42 (52.5%) on the left side. The locations were in the frontotemporoparietal region in 91.25% patients and in the frontoparietal region in 8.75% patients. The mean duration of symptoms was 4.62 days ± 5.20 SD. History of trauma was present in 58.75% patients. The mean duration of trauma was 45.78 days ± 28.32 SD. The most common symptoms were weakness of the limbs (68.75%), altered sensorium or decreased memory (52.5%), and headache (32.5%). The preoperative Glasgow Coma Scale (GCS) score ranged from 4 to 15 (mean 12.86 ± 2.98 SD). Limb motor weakness was noted in 75% patients. The maximum thickness of the CSDH (in millimeter) in axial CT scan was 8 to 32 (mean 23.22 ± 4.87 SD). All of the 80 patients had MLS. Postoperative GCS ranged from 3 to 15 (mean 14.1 ± 2.78 SD). Postoperative power was improved in 95% of affected limbs. Postoperative power was deteriorated (including patients of complications and death) in 5% patients. Clinical improvement was noted in 93.75% patients. Postoperative CT scan improvement was noted in 95% patients. Two patients (2.5%) had significant residue which required reoperation. Two patients (2.5%) developed extradural hematoma which was operated. Five (6.25%) patients developed complications, among which 4 (5%) patients died. The mean duration of stay in the hospital was 6.82 days ± 4.16 SD.Conclusions CSDH is a disease of elderly population. CSDH is more common in male population. The most common symptom is weakness of the limbs. High clinical and radiological improvement can be achieved with TDC. TDC should be considered as a safe and effective alternative to burr hole craniostomy.

Chronic subdural hematoma: Differences between unilateral and bilateral occurrence

To identify factors determining the clinical characteristics and prognosis of acute subdural hematoma (ASDH) arising from boxing injuries by comparing with ASDH due to any nonboxing cause. Two groups were selected for this study: 10 patients with ASDH because of boxing injuries and 26 patients with nonboxer ASDH. All of the patients underwent neurologic examination by neurosurgeons. Primary resuscitation and stabilization as well as operative therapy were performed to all patients according to the European Brain Injury Consortium Guidelines. Two groups were compared in terms of age, the Glasgow Coma Scale at admission, neurologic findings, craniogram and brain computed tomography scan findings, operative findings, and prognosis. As potential prognostic indicators for boxers, the time interval until surgery, the Glasgow Outcome Scale, hematoma thickness, midline shift, and the site of bleeding were analyzed. The characteristics of patients because of boxing injuries are that patients were younger, had lucid interval, and had no cerebral contusion or contralateral brain injury. There was no significant difference in initial Glasgow Coma Scale, hematoma thickness, midline shift, and their prognosis. The most peculiar clinical presentation of boxers' ASDH was that all bleedings were limited from "bridging veins" or "cortical veins." The prognosis of boxers was most closely correlated with the site of bleeding (r2 = 0.81; p = 0.0001) and the midline shift (r2 = 0.67; p = 0.007). Our study shows that ASDH because of boxing is characterized by bleeding from bridging or cortical veins, and that the site of bleeding is a significant determinant of their prognosis.

Computed tomographic data from 174 patients with acute subdural hematoma were analyzed statistically to identify parameters that could be evaluated independently of clinical and neurological status to estimate outcome. This retrospective study was made necessary by the fact that the patients admitted usually had been treated with intubation, sedation, and artificial ventilation, which precludes neurological examination. In surgically treated patients, the hematoma thickness ranged from 5 to 35 mm and the midline shift was 0 to 33 mm. In 81 patients (46.6%), the hematoma thickness was greater than the midline shift; in 24 patients (13.8%), the hematoma thickness equaled the midline shift; and in 69 patients (39.6%), the midline shift exceeded the hematoma thickness. Of the patients, 52% died after surgery, for 29% we obtained good or satisfying results, and 19% were in poor condition after therapy. The Kaplan-Meier survival analysis proved that the survival rate was only 50% for a hematoma thickness of approximately 18 mm and a midline shift of 20 mm. The survival function dropped markedly for midline shifts of more than 20 mm and converged to 0% for midline shifts of more than 25 mm. If the midline shift exceeded the hematoma thickness by 3 mm, the survival function was 50%; when the midline shift exceeded the hematoma thickness by 5 mm, the survival function was 25%. The Glasgow Outcome Scale scores were correlated significantly with these parameters. The parameters, which are the measured hematoma thickness, the midline shift, and the difference between the hematoma thickness and the midline shift, allow robust/adequate estimation of survival function and outcome for patients suffering from acute subdural hematoma. Based on these data, indications for surgery could be assessed by means of video conferencing, i.e., without personal examination of the patients.

BackgroundTraumatic acute subdural hematoma has a high mortality despite intensive treatment. Despite the existence of several prediction models, it is very hard to predict an outcome. We investigated whether a specific combination of initial head CT-scan findings is a factor in predicting outcome, especially non-survival.MethodsWe retrospectively studied admission head CT scans of all adult patients referred for a traumatic acute subdural hematoma between April 2009 and April 2013. Chart review was performed for every included patient. Midline shift and thickness of the hematoma were measured by two independent observers. The difference between midline shift and thickness of the hematoma was calculated. These differences were correlated with outcome. IRB has approved the study.ResultsA total of 59 patients were included, of whom 29 died. We found a strong correlation between a midline shift exceeding the thickness of the hematoma by 3 mm or more, and subsequent mortality. For each evaluation, specificity was 1.0 (95 % CI: 0.85–1 for all evaluations), positive predictive value 1.0 (95 % CI between 0.31–1 and 0.56–1), while sensitivity ranged from 0.1 to 0.23 (95 % CI between 0.08–0.39 and 0.17–0.43), and negative predictive value varied from 0.52 to 0.56 (95 % CI between 0.38–0.65 and 0.41–0.69).ConclusionsIn case of a traumatic acute subdural hematoma, a difference between the midline shift and the thickness of the hematoma ≥ 3 mm at the initial CT predicted mortality in all cases. This is the first time that such a strong correlation was reported. Especially for the future development of prediction models, the relation between midline shift and thickness of the hematoma could be included as a separate factor.

Aims: This study aimed to investigate the therapeutic effectiveness of decompressive craniectomy in patients with traumatic acute subdural hematoma and stroke patients and to determine the parameters that could predict the risk of mortality in these patients. Methods: Patients diagnosed and operated on with acute subdural hematoma (ASH) or stroke between January 2022 and September 2023 were grouped into the ASH group and the CVO group. The patients were also divided into DEAD and SURVIVED groups according to mortality. Age, gender, anisocoria, the area of the craniectomy field, length of stay in the intensive care unit (ICU), length of stay in the hospital, and Glasgow Outcome Scale scores were recorded. In addition, Glasgow Coma Scale (GCS) scores, the amount of midline shift, and the blood biochemistry results were recorded pre-and postoperatively. Results: This study consisted of 11 (5 male and 6 female) patients. Sex, preoperative GCS score, anisocoria, postoperative sedation anesthesia time, postoperative GCS score, duration of stay in the ICU, preoperative serum blood urine nitrogen, preoperative serum C-reactive protein (CRP), postoperative neutrophil-to-lymphocyte ratio, and postoperative CRP values were different between the ASH and CVO groups (p&lt;0.05). Furthermore, the preoperative GCS score, postoperative GCS score, postoperative sedation anesthesia duration, postoperative serum aspartate aminotransferase (AST), and postoperative serum CRP level values were different between the DEAD and SURVIVED groups (p&lt;0.05). The correlation analysis results revealed a positive correlation between mortality and preoperative GCS score and a negative correlation between mortality and anisocoria (p&lt;0.05). The ROC-curve analysis revealed that preoperative GCS and postoperative GCS score, postoperative midline shift, postoperative serum AST level value, and postoperative serum CRP level value could predict mortality risk (p&lt;0.05). However, Logistic Regression analysis showed that any study parameter could be used as the best marker for prediction of the postoperative mortality risk (p&gt;0.05). Conclusion: This study showed that decompressive craniectomy may offer more satisfactory results in severe head trauma patients. It was also argued that preoperative and postoperative GCS scores, postoperative midline shift values, and postoperative serum AST and CRP level values could be used to predict mortality risk.

Background:Chronic subdural hematoma (CSDH) is a common neurosurgical condition, particularly among the elderly, that often requires surgical drainage. Due to economic and logistical constraints, traditional closed-system drains are often impractical in low- and middle-income countries (LMICs). Foley catheter drainage has also been proposed as a cost-effective alternative, yet few studies have evaluated its safety and efficacy. This study investigates the clinical outcomes of patients with CSDH who underwent Foley catheter drainage, focusing on its effectiveness and safety.Materials and methods:This retrospective analysis examined the case records of 134 patients who underwent burr-hole craniotomy with Foley catheter drainage for chronic subdural hematoma (CSDH) at our hospital from January 2022 to December 2024. Patient demographics, presenting symptoms, postoperative recovery, recurrence rates, and complications were assessed. Statistical analysis, including Chi-square tests and Pearson correlation, was conducted using SPSS 28, with a significance threshold set at P < 0.05.Results:One hundred thirty-four patients were studied, with a mean age of 61.8 years and male predominance (80.6%). The most frequent presenting symptoms were headache (77.6%) and motor deficits (55.97%). Postoperative recovery was satisfactory, with 85% of patients making a complete recovery. The rate of recurrence was 3.7%, and the most common complications were pneumocephalus (7.5%) and infections (5.2%). There was a positive correlation (r = 0.48, P < 0.0001) between preoperative Glasgow Coma Scale (GCS) scores and functional recovery. However, it was not strong enough to serve as a stand-alone predictor, and clinical correlation, which considers other variables, needs to be taken into consideration while interpreting. The mortality rate was 3%.Conclusion:Foley catheter drainage of cerebrospinal fluid (CSF) hygroma (CSDH) can be considered a reliable and safe alternative in low- and middle-income countries (LMICs), with recovery rates of 85% and a low risk of recurrence. However, further prospective studies are required to prove these findings, as this is a single-arm retrospective study. Though complications were tolerable, attention to surgical technique and vigilant postoperative observation continues to be vital. Further studies and refinement of management are warranted to confirm these results.

Objectives: The effect of routine blood biochemistry parameters on the short-term prognosis of patients with chronic subdural hematoma (CSDH) has not been evaluated in literature before. In this study, it was aimed to establish markers for determination of short-term prognosis using data of patients who were operated for CSDH. Methods: During admission to hospital, data of patients including age, sex, antiaggregan and/or anticoagulant drugs usage, comorbidity, Glasgow Coma Scale (GCS) and Glasgow Outcome Scale scores were evaluated. Location and thickness of CSDH were recorded using brain CT or MR images. Blood leukocyte, neutrophil, lymphocyte, eosinophil, basophil, platelet count results, neutrophil-lymphocyte ratio and platelet-lymphocyte ratio results, activated prothrombin time and INR values, serum glucose, aspartate aminotransferase, alanine aminotransferase, C-reactive protein, sodium, potassium, blood urea nitrogen and creatinine level values were also recorded. Patients were divided into two groups according to CSDH located “unilaterally (n=19)” and “bilaterally (n=12)”. In addition, patients with unilateral CSDH were divided into two groups as CSDH located at the "right hemisphere (n=6)” and "left hemisphere (n=13)". Results: It was concluded that short-term prognosis of patients with unilateral or bilateral CSDH was similar. Correlation analysis showed no correlation between short-term prognosis and demographic, clinical and laboratory findings. However, Likelihood Ratio test revealed that GCS score could be a biomarker in order to predict short-term prognosis of these patients, albeit weak (X2=6.138, p=0.046). Conclusion: It was thought that GCS scores could be effective in predicting short-term prognosis in patients with CSDH but routine biochemistry laboratory parameters could not predict short-term prognosis of these patients.

Chronic subdural hematomas (CSDHs) are the among the most common conditions treated by neurosurgeons. Midline shift (MLS) is used as a radiological marker of CSDH severity and the potential need for urgent surgical evacuation. However, a patient's age may affect the degree of MLS for a given hematoma volume. This study aimed to investigate the correlation between the patient's age and the MLS caused by CSDH. The database of patients treated for CSDH was reviewed in a single institution. Patients with unilateral CSDH were included. To measure CSDH volume, the preprocedural head CT scans underwent 3D volumetric reconstruction using the TeraRecon software. The effect of age on MLS after adjusting for CSDH volume was investigated using linear regression analysis. Sixty-nine hematomas in 69 patients were included. The age of patients ranged from 25 to 94 years (mean 71.6 years). Hematoma volume and MLS ranged from 27.8 to 215 mL (mean 99.3 mL) and 0-17 mm (mean 6.5 mm), respectively. On multivariate regression analysis, MLS showed a significant independent negative correlation with age after adjusting for CSDH volume (OR -0.11, 95% CI -0.16 to -0.06; p < 0.001), meaning that for a fixed CSDH volume, with each 10-year increase in age the MLS will reduce by 1.1 mm. Moreover, MLS-to-volume ratio showed a significant negative linear correlation with age (r2 = 0.32; p < 0.001). Ten-milliliter increments in CSDH volume resulted in a 1.09-mm increase in MLS in patients younger than 60 years, which is 2.4-fold higher compared to the 0.46-mm increase in those older than 75 years (p < 0.001). For a fixed CSDH volume, older age correlates with significantly lower MLS. This could be explained by higher parenchymal compliance in older individuals due to increased brain atrophy, and a larger subdural space. Clinical use of MLS to estimate severity of CSDH and gauge treatment decisions should take the patient's age into account.

Objective: For traumatic brain injury (TBI), therapeutic hypothermia (TH) has not shown efficacy in multicenter randomized controlled trials (RCTs). From the latest RCT (NABISH II and BHYPO), we hypothesized that preoperatively early-induced TH may be beneficial specifically in acute subdural hematoma (ASDH) patients who need evacuation. The aim of this project was thus 1) to test the efficacy of TH in an experimental rat model and 2) to translate these results to a multicenter RCT. Methods and Results-Experimental Study: Under anesthesia ASDH was induced, and the rats were placed into: 1) normothermia (37C) and 2) early-induced TH (33C, 30 minutes prior to decompressive craniotomy and ASDH removal). Results: The number of degenerating cells, extracellular biomarkers (UCH-L1 and GFAP), and injury volume were significantly smaller in the early hypothermia group than for normothermia. Conclusion and Future Implication for Multicenter RCT: Our experimental results suggested that preoperatively early-induced TH could mediate the reduction of neural damage in ASDH. Therefore, we are initiating a multicenter RCT both in JAPAN and US. This trial will employ several novel features as below: 1) The trial will enroll only ASDH patients who need emergency surgery 2) The trial will determine whether preoperatively induced hypothermia alters biomarkers and improves outcome, using a new intravascular cooling device, Quattro , for extra-rapid cooling. The study is conducted with the generous support of the Vivian L. Smith Foundation for Neurologic Research and in kind support from ZOLL Circulation.