Burr Hole Craniotomy Research Articles

Risk of recurrence of subdural hematoma after EMMA vs surgical drainage - Systematic review and meta-analysis.

ObjectiveChronic subdural hematoma (CSDH) is a common and debilitating neurological condition whose treatments, including burr hole drainage and craniotomy, suffer from high rates of recurrence and complication. Embolization of the middle meningeal artery (EMMA) is a promising minimally invasive approach to manage CSDH in a broad set of patients.MethodsTo evaluate the efficacy and safety of EMMA, a database search was conducted including the terms “subdural hematoma; embolization; embolized; middle meningeal” was performed and yielded a total of 260 results. Following exclusion based on predefined criteria, a total of four studies were identified and outcomes including recurrence rates and complication rates were extracted for analysis.ResultsFour studies including intervention and control groups were included with a total of n = 888 patients. The relative risk of CSDH recurrence in the EMMA (3.5%) compared to control group (23.5%) was significantly reduced when EMMA was performed (risk ratio = 0.17; 95% confidence interval (CI) 0.05–0.67). In addition, rates of complication were not significantly different between patients with conventional therapy and those who received EMMA (OR = 0.77; 95 confidence interval (CI) 0.3–1.99).ConclusionBased on limited data, EMMA reduces the risk of recurrence by 20% compared to surgical treatment for CSDH.

Clinical Presentation and Surgical Outcomes of Chronic Subdural Hematoma

Objective: The aim of this study was to access clinical presentation of chronic subdural hematoma and to evaluate the surgical outcome of evacuation of chronic subdural hematoma after single burrhole craniotomy with a close drainage system under local anesthesia.
 Material & Methods: A descriptive study conducted in the Neurosurgery Department of Khairpur Medical College Sindh. 30 patients of chronic subdural hematoma were included. Patients prepared for evacuation of chronic subdural hematoma through single burr hole followed by closed drainage system for two days.
 Results: The most common feature was gait disturbance followed by Hemiparesis and headache. Coexisting diseases were hypertension, Diabetes mellitus and Chronic Liver Disease, etc. and causes of CSDH were head injury (trivial trauma) and anticoagulant. Surgical decisions were taken on the bases of clinical presentation and radiological findings of patients. Surgical procedure single burrhole craniotomy followed by irrigation with normal saline and close drainage system for two days. On post-operative follow-up, a recurrence of CSDH occurred in two patients.
 Conclusion: Single burrhole craniotomy with close drainage system is a simple and safe procedure under local anesthesia for treatment of chronic subdural hematoma.
 Keywords: CSDH (chronic subdural hematoma), GCS (Glasgow coma score), Burrhole craniotomy, Neurosurgery & Subdural drain.

Comparative analysis of craniotomy methods in severe traumatic brain injury

The goal of research: to improve the results of neurosurgical management in patients with traumatic brain compression by detecting an optimal way of craniotomy.Material and methods. The study includes data of 127 patients with traumatic brain compression. The series consisted of 109 (85.8 %) males and 18 (14.2 %) females out of examined. The patients’ age ranged from 16 to 85 years. The neurosurgical interventions were performed in all patients with traumatic brain compression.Results. The patients with traumatic brain compression regardless of craniotomy method (burr hole surgery, craniectomy, osteoplastic craniotomy) did not experience a statistically significant difference in the outcome. When planning a method of craniotomy in traumatic brain compressio, the grade of consciousness impairment on the Glasgow coma scale, brain contusion foci, acute subdural and intracerebral hematomas, brain compression, patients’ age and brain dislocation syndrome should be considered that predicts an outcome.Conclusion. The results of a burr hole, resection, and osteoplastic craniotomy revealed no significant differences in outcome in patients with traumatic brain injury. Resection craniotomy in traumatic brain injury may be effective enough even in deep coma and dislocation syndrome but in absence of intraoperative brain edema. The absence of brain edema, the moderate coma level are indications for osteoplastic craniotomy.

Tips and Pearls in Chronic Subdural Hematoma

Background and Aim: One of the most prevalent neurosurgery conditions is Chronic Subdural Hematoma (CSDH). Among neurosurgeons, there are various CSDH treatment approaches. Methods and Materials/Patients: This is a narrative review examining the various aspects of the CSDH. To provide up-to-date information on CSDH, we concisely reviewed the related articles. All of the relevant articles retrieved from Google Scholar, PubMed, and Medline were reviewed and critically analyzed. We searched for keywords including chronic subdural hematoma, burr hole craniotomy versus craniostomy, middle meningeal artery embolization, conservative therapy versus surgical therapy in CSDH, and recurrence of CSDH in published articles from 1960-2020. Results: CSDH may present with various clinical presentations. Medical symptoms range from general and moderate symptoms (such as headache, tiredness) to severe symptoms (e.g. hemiparesis, coma). A definite trauma history may be obtained in most cases. Contrast-enhanced CT or MRI may help diagnosis. The treatment choice for uncomplicated CSDH is Burr-Hole Craniotomy (BHC). The use of drainage to decrease recurrence rates has been shown to have limited outcomes in most recent studies. Craniotomy is also used for treatment. Only asymptomatic or high-risk operative patients are subjected to non-surgical management. Conclusion: Management of CSDH is still contentious. It is widely agreed that if neurological signs and radiological observations are present, CSDH should be evacuated. Burr-hole craniotomy appears to be the preferred surgical technique because, in most patients, it gives the best treatment outcomes. Several issues are still uncertain, including the proper surgical technique [Burr-hole craniotomy versus Twist Drill Craniostomy (TDC) and craniotomy], the advantage of 2 perforated holes over one, the location of drainage, the impact of irrigation of the hematoma, and the duration of post-operative immobilization.

Endoscopic Management of Chronic Subdural Hematoma.

Twist drill evacuation, burr hole aspiration, mini-craniotomy, and craniotomy are some of the surgical methods to remove chronic subdural hematoma (CSDH). Endoscopic treatment was also recently found to be useful. We conducted a prospective study of 72 hematomas in 68 patients. Computed tomography was performed in all cases. Endoscopic surgery was performed in all CSDH patients. A 4-cm skin incision was performed at the most curved part of skull with the CSDH. A mini-craniotomy or enlarged burr hole was made. The inner and outer table of the burr hole margin was drilled to provide a straight trajectory to the hematoma cavity. An endoscope supported by a telescope holder was used. A modified silicone brain retractor was used in five patients. A subgaleal drain was left in all patients for 3 to 5 days. There were 42 male and 26 female patients. The age ranged from 45 to 79 years (average: 69 years). All patients had a history of head trauma. Preoperative average Glasgow Coma Scale Score was 14. The procedure was effective in hematoma evacuation and a good visualization of the whole cavity in all patients. The endoscopic technique helped in complete hematoma removal in organized/solid clot, septations, and bridging vessels in 17, 2, and 2 cases, respectively. Duration of surgery ranged from 35 to 80 minutes. One death occurred. There was no recurrence, infection, fresh bleed, or injury to the brain or membrane. The endoscopic technique is an effective alternative technique for treating CSDH. Although the study has limitations because of the small number of patients with a short follow-up, the study indicated that thick and vascular membranes, septations, and organized and solid clots can be removed effectively using this technique.

Critical Depressed Brain Volume Influences the Recurrence of Chronic Subdural Hematoma after Surgical Evacuation

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.

Single versus Double Burr Holes for Treating Chronic Subdural Hematoma

A subdural hematoma is a collection of blood below the inner layer of the dura but external to the bran and arachnoid membrane.Chronic subdural hematoma is commonly associated with cerebral atrophy, occur in the elderly after apparently insignificant head trauma. The incidence of Chronic subdural hematoma increases with age and after 70 years of age. Surgical evacuation of hematoma is indicated in patients who are clinically deteriorate or do not improve. Surgery can bring a rapid clinical improvement with a favorable outcome in over 80% of patient.&#x0D; Methods: This study was a prospective intervention study.&#x0D; Results: It was observed that 29 (96.6%) patients were alive in group A and 27 (90.0%) patients alive in group B in GOS scoring on the 7th POD. The alive patients were again divided into 4 sub groups, as shown in the table. Among total 60 patients, in Group A 1(3.4%) died and 3 (10.0%) died in Group B. After 3 months follow up, it was observed that 29 (96.6%) patients were alive in group A and 27 (90.0%) patients alive in group B. The alive patients were again divided into 4 sub groups, as shown in the table. Persistent vegetative and severe disability was not improved in Group B.&#x0D; Conclusion: In my study it was observed that the surgical outcome in single burr hole craniotomy is better than double burr hole craniotomy for treating of chronic subdural hematoma.&#x0D; Bang. J Neurosurgery 2020; 9(2): 99-104

A Comparison of Subperiosteal or Subgaleal Drainage with Subdural Drainage on the Outcomes of Chronic Subdural Hematoma: A Meta-Analysis

The aim of the present study was to compare the outcomes of patients with chronic subdural hematoma after undergoing burr hole craniotomy with subperiosteal or subgaleal drainage (SPGD) with those of patients who have undergone burr hole craniotomy with subdural drainage. We searched 4 databases (PubMed, Web of Science, Embase, and Cochrane Library) for relevant reports from January 1995 to September 2019. Two reviewers recorded the major outcomes data as follows: recurrence, mortality, postoperative seizures, postoperative bleeding events, surgical infection, pneumocephalus, modified Rankin scale scores, and Glasgow outcome scale scores. The pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. A total of 3149 patients from 10 studies were included in our analysis. Compared with the SSD group, the SPGD group had a lower recurrence rate (OR, 0.72; 95% CI, 0.57-0.91) and a smaller risk of postoperative bleeding (OR, 0.41; 95% CI, 0.22-0.78). Also, no significant differences were found in the incidence of mortality (OR, 0.79; 95% CI, 0.54-1.18), postoperative seizures (OR, 0.74; 95% CI, 0.39-1.40), surgical infection (OR, 0.98; 95% CI, 0.55-1.76), pneumocephalus (OR, 0.58; 95% CI, 0.28-1.20), modified Rankin scale score 0-3 (OR, 1.04 at discharge; OR, 1.33 at 6 months), and Glasgow outcome scale score 4-5 (OR, 1.48; 95% CI, 0.82-2.67). Burr hole craniotomy with SPGD can be recommended as an effective and safe surgical therapy for patients with chronic subdural hematoma owing to its lower recurrence rate and reduced incidence of postoperative brain injuries, in addition to no increase in the rate of some postoperative complications. However, more studies are necessary for further confirmation.

Morbidity and Mortality After Burr Hole Craniostomy Versus Craniotomy for Chronic Subdural Hematoma Evacuation: A Single-Center Experience

Chronic subdural hematomas (cSDHs) are common neurosurgical pathological entities and typically occur after trauma in elderly patients. The 2 most commonly used strategies for treatment have included burr hole drainage and craniotomy with decompression. However, the choice of these procedures has remained controversial and has been primarily determined by surgeon preference. We designed a matched-cohort analysis to compare these 2 procedures and identify the risk factors associated with the postoperative outcomes. Thus, we compared the rates of reoperation and mortality for patients who had undergone craniotomy versus burr hole evacuation for cSDH. A retrospective review examining the data from 299 consecutive patients with cSHDs from 2002 to 2015 was performed. We compared the following endpoints between the 2 procedures: 30-day mortality, discharge to a skilled nursing facility, and the need for reoperation. We also compared the potential risk factors in the patients with different primary outcomes. Patients undergoing craniotomy had a decreased need for reoperation compared with patients treated with burr hole evacuation (7.5% vs. 15.7%; P= 0.044). Older age was associated with both increased disposition to a nursing facility and increased 30-day mortality in both groups. Increased 30-day mortality was associated with aspirin usage in patients who had undergone craniotomy and with warfarin (Coumadin) in patients who had undergone burr hole evacuation. Our study identified an increased need for reoperation for patients treated with burr hole evacuation compared with those undergoing craniotomy. Older age and low Glasgow coma scale scores were associated with worse outcomes in both groups. Certain methods of anticoagulation were also associated with worse outcomes, which varied between the 2 groups. We recommend that surgeons individualize the choice of procedure according to the specific patient characteristics with consideration of these findings.

Craniofacial Skills: A 2-Site Validation of Assessments to Aid Plastic Surgery Resident Milestone Achievement in Technical Skills and Instrument Knowledge.

Plastic surgery evaluates residents on milestones. This study defines a model of education including pre and post-test assessments paired with didactics intended for evaluating residents in the unique technical skills of craniofacial surgery. At the first institution, instrument identification, and time/accuracy of burr hole placement, craniotomy, and plating on Saw Bones Craniofacial Models were tested before and after a 7.5-hour craniofacial orthognathic surgery workshop. At the second institution, this was refined, removing plating, eliminating assessment of timing, and shortening didactics to standard osteotomies, instrument names, and common surgical approaches. The study population consisted of junior, mid-level, and senior residents on 2 different University craniofacial services. Participant performance was analyzed by level of training: junior, midlevel and senior resident. In the first iteration, resident times improved significantly for all 4 tasks (P = 0.008, 0.035, 0.035, 0.016). Resident accuracy improved significantly for instrument naming (P = 0.003). Except for instrument naming, resident year did not impact improvement (timing: P = 0.062, 0.310, 0.125, 0.334; accuracy: P = 0.029, 0.664, 0.717, 0.306). In the second iteration, resident accuracy improved for all tasks (instrument naming P = 0.00002, burr holes P = 0.0031, craniotomy P = 0.08). There was no difference in rate of improvement between resident cohorts. The task-based assessment with resident education on basic craniofacial surgery skills, standard osteotomies, and instrument names directed resident learning and assessed resident knowledge. With the removal of time as a metric, all tasks improved in accuracy. The craniofacial skills task-assessment successfully evaluated milestone attainment in a reproducible model.

Postoperative Admission of Adult Craniotomy Patients to Neuroscience Floor Unit Reduces Cost and Length of Stay

Abstract INTRODUCTION The neurointensive care unit (NICU) is costly but has traditionally been the default recovery unit after adult elective craniotomies for brain tumor resection. Given the rising healthcare costs and associated change in practice patterns, we assessed whether admitting these patients to a neuroscience floor unit instead of NICU for recovery resulted in an equivalent outcome while reducing the cost and length of stay. METHODS We retrospectively analyzed the clinical and cost data of all adult brain tumor elective supratentorial craniotomy patients at a university hospital within the last 5 yr who had a length of stay of less than 7 d. We compared those who stayed in the ICU for 1 d during admission versus those who did not stay in the ICU. Patients undergoing shunts, endoscopic, burr hole craniotomies, posterior fossa craniotomies, and vascular procedures were excluded. RESULTS A total of 688 patients were included, with 428 patients staying in the NICU for 1 d (NICU1) and 259 not staying in the NICU (NICU0). There was no difference in University Hospital Consortium (UHC) expected length of stay (P = .338). However, the actual length of stay for the NICU1 group was 12 h longer than the NICU0 group (3.6 vs 3.1 d) (P &lt; .0001), and the difference was still significant in multivariate analysis controlling for age, MS DRG, OR hours, insurance type, discharge disposition, and admit day. While the NICU1 group had longer surgeries (mean OR hours charged 6.8 vs 6.5 h), there was no statistically significant difference in the cost of surgery. The NICU0 group reduced the direct hospital cost by $3070 per admission on average (P &lt; .001). Clinically, there were no statistically significant differences in the rate of return to OR, ED readmission, or hospital readmission within 30 d. CONCLUSION Admitting to a neuroscience floor unit reduced the length of stay and direct hospital cost associated with admission, without significant differences in clinical outcome.

The Protective Role of Heme Oxygenase-1 (HO-1) in Chronic Subdural Hematoma

Abstract INTRODUCTION Many studies have revealed that angiogenesis and inflammation are closely linked to the pathophysiology of chronic subdural hematoma (CSDH). The development of CSDH is an inflammatory process that begins as a local inflammatory reaction of the dura meter to injury or external stimuli such as blood or CSF. This process causes neovascularization of the outer membrane of CSDH and vascular hyperpermeability. Heme oxygenase-1 (HO-1) is a key enzyme that catalyzes the degradation of heme and produces biliverdin, ferrous iron, and carbon monoxide. HO-1 expression is induced by oxidative stress, and the increasing expression seems to be protective in animal studies. We hypothesized that HO-1 has a protective impact on the severity of CSDH. METHODS This study is designed to correlate the histopathology of the outer membrane of CSDH and HO-1 level in the CSDH hematoma as an indicator of inflammatory status with the clinical presentation of patient and computed tomography (CT) radiological findings of a consecutive series of patients suffered from CSDH. This is a single-center, perspective cohort study. From 2014 to 2017, we enrolled 97 patients with CSDH, who has undergone surgical intervention (burr-hole drainage or craniotomy evacuation). We collect the clinical data, radiological information, and outer membrane and supernatant of the CSDH. We use enzyme-linked immunosorbent assay (ELISA) to measure the concentration of HO-1 in the supernatant of CSDH. RESULTS A significant negative correlation between the HO-1 and the thickness of CSDH is noted (P = .001). On increasing HO-1 by 1 ng/L, the CSDH thickness decreases by 81 mm (P &lt; .005). CONCLUSION Our study demonstrates that HO-1, an important enzyme in angiogenesis and in the inflammation pathway, has a key impact on CSDH severity. A significant negative correlation between the HO-1 and thickness of CSDH has been proved.

Treatment Outcomes of Burr-Hole Surgery for Chronic Subdural Hematoma in the Elderly Living Beyond Life Expectancy: A Study Comparing Cure, Recurrence, and Complications in Patients Aged ≥80 Years versus ≤79 Years

Few reports have focused on chronic subdural hematoma (CSDH) in the very elderly, who have lived beyond average life expectancy. Our aim is to appraise treatment outcomes of burr-hole craniotomy for CSDH in the elderly, focusing on cure, recurrence, and complications. Fifty patients ≤79 years of age (group A) and 73 patients ≥80 years of age (group B) were studied. Recurrence was defined as requiring reoperation for hematoma regrowth or symptomatic failure. A cure was regarded as having been achieved in the absence of hematoma on postoperative computed tomography. Complications were defined as any harmful event related to the treatment procedure for CSDH. Cure was documented in 31 patients in group A (63%) and 24 patients in group B (33%) (P= 0.0017). Median intervals to cure were 2.76 and 3.73 months, respectively (P= 0.06). Cumulative cure rates were 51%/76% and 36%/59%, respectively, at the sixth/twelfth postoperative months. Recurrence was documented in 2 patients (4%) and 11 patients (15%), respectively (P= 0.07). Median intervals to recurrence were 0.81 and 1.25 months, respectively (P= 0.049). Cumulative recurrence-free rates were 96%/92% and 87%/75%, respectively, at the third/sixth postoperative months. Complications were observed in 2 patients (4%) and 4 patients (5%), respectively (P= 1.00). With advancing age, CSDH might show a greater tendency to recur and a longer time is required to achieve a cure. However, complications developed only in high-risk patients. Thus, surgical treatment for CSDH in elderly patients, even those who have lived beyond life expectancy, might provide acceptably effective results.

Efficacy of Trauma Catheter and Mushroom Tip Catheter in Evacuation of Chronic Subdural Hematoma and Complications of Drain Placement.

ObjectiveThe aim of this study was to assess the efficacy and complications of trauma catheter versus mushroom tip catheter placement in the evacuation of chronic subdural hematoma via twist drill craniostomy with closed system drainage.BackgroundChronic subdural hematoma (cSDH) is one of the most frequent neurosurgical pathologies in patients >70 years of age with an estimated incidence of 8.2 per 100,000 people per year. The most common risk factors for cSDH are advanced age, alcohol abuse, seizures, cerebrospinal fluid (CSF) shunts, coagulopathies, blood thinners, and patients at risk for falling. Twist drill craniostomy can be performed at the bedside under local anesthesia, making it an attractive treatment option, especially in poly-morbid patients who are poor surgical candidates. A closed drainage system is placed at the time of surgery to allow continuous drainage and promote postoperative brain expansion. Despite the increasing prevalence, limited literature exists to guide surgical management, particularly in terms of drain management and selection of catheter. MethodsThis is a retrospective review of 205 patients from January 2007 to May 2017 at two-level high volume centers for the evaluation and treatment of cSDH. Inclusion criteria include patients >18 years of age with the radiographic presence of a subdural hematoma for greater than three weeks. All patients were managed with either a trauma catheter or mushroom tip catheter. All patients received computed tomography (CT) of the head without contrast prior to subdural drain placement and within 24 hours after subdural drain removal. Exclusion criteria include patients <18 years of age and patients with depressed skull fractures, vascular malformations, subdural empyema, subdural hygroma, or who initially underwent open craniotomy or burr-hole craniotomy.ResultsDrain efficiency in evacuating the cSDH was assessed using both radiographic and clinical markers. Analysis of 205 patients treated by twist drill craniostomy and the subsequent closed system drainage utilizing either the mushroom tip catheter or trauma catheter revealed that neither catheter was superior in producing a statistically significant change in the maximum thickness of the cSDH (p = 0.35) and midline shift (p = 0.45). Furthermore, when assessing patients clinically via utilization of the Glasgow Coma Scale (GCS), both the trauma catheter and the mushroom catheter did not show a statistically significant difference in improving GCS after the evacuation of the cSDH (p = 0.35). Neither catheter was associated with an increased incidence of hemorrhage with drain placement requiring open surgery (p = 0.12), need for additional drain placement (p = 0.13) or decline in GCS with intervention (p = 0.065).ConclusionAnalysis of the 205 patients treated by twist drill craniostomy with closed system drainage for the evacuation of chronic subdural hematoma utilizing either the mushroom tip or trauma catheters revealed that neither catheter was statistically significant in radiographic or clinical improvement in evacuating cSDH. Furthermore, neither catheter was found to be associated with an increased complication risk.

A Self-Made, Reusable, and Adjustable Device for Making Burr Hole Bone Plugs: Doing More with Less

Burr hole craniotomy is a daily procedure in neurosurgery. Defects after burr hole craniotomies will not spontaneously heal and can result in skin dents and cosmetic dissatisfaction. We have introduced a self-made, reusable, and adjustable bone plug packer to use in the repair of burr holes via packing of autologous bone dust. Our bone plug packer is free of charge and can be readily available in neurosurgical operating rooms. We have produced a stainless steel bone packer device that can be assembled without the use of a special wrench. The instrument consists of a container plate and a main cylinder for packing, in which an adjustable airtight piston is placed to compress the bone dust and create a bone plug of the desired dimensions. Some recent studies have shown that burr holes filled by autologous bone dust will result in good cosmetic and osteogenic outcomes. Although we did not perform a long-term follow-up assessment of the burr holes filled with bone plugs, in the short term, we have not seen any local reactions or infections in our patients. The autologous bone plug is a more affordable and available option with no technical or clinical complications in the short term. We have introduced a practical, convenient, and cost-effective bone packer device. Bone plugs formed using our device can be a potential substitute for expensive covering materials in countries with limited access to other repair options. Providing proper evidence will require the performance of large studies to assess our suggested method in the long term and, possibly, compare it with the usual options in controlled studies.

Midterm Follow-Up of Patients with Middle Meningeal Artery Embolization in Intractable Chronic Subdural Hematoma

A subset of patients with chronic subdural hematoma (CSDH) remains refractory to standard treatment with hematoma drainage by burr-hole craniotomy and irrigation. We recently reported the usefulness of middle meningeal artery (MMA) embolization for intractable CSDH in patients with multiple intractable risk factors. We present the midterm outcomes of MMA embolization in patients with intractable CSDHs. Seventeen consecutive patients (average age, 76.4 years; 12 men [71%]) underwent MMA embolization of CSDH from January 2014 to July 2017. Earlier interventions included embolization using N-butyl-2-cyanoacrylate (although trisacryl gelatin microspheres were used in recent cases), followed by burr-hole craniotomy and irrigation in all cases. None of the patients experienced perioperative complications or postoperative recurrence. The modified Rankin Scale scores, which were unfavorable at admission, improved significantly at discharge but were comparable to those at the time of hospitalization when measured during the follow-up period. Although the patients required rehospitalization at other departments for unrelated causes, none required rehospitalization in our department. Despite the known unfavorable outcomes of patients with intractable CSDHs, MMA embolization was not associated with recurrent CSDH or rehospitalization in our department in the current case series. MMA embolization should be considered a preferred therapeutic option for intractable CSDHs.

Multiple Septic Emboli in the Skin, Lungs, and Brain due to Corynebacterium Striatum Bacteremia in a Patient with Acute Myelogenous Leukemia

A 29-year-old man developed fever after chemotherapy for acute myelogenous leukemia. Corynebacterium striatum was detected via blood culture, and antibacterial treatment with vancomycin started. In the course of treatment, papules of the skin, multiple nodular shadows of the lung, cerebral infarction, and subdural empyema appeared. A diagnosis of multiple septic emboli in the skin, lungs, and brain due to C. striatum bacteremia was made from the clinical course. The antibacterial treatment improved skin and pulmonary lesions. The subdural empyema was considered as a postoperative infection of burr-hole craniotomy. It improved by performing craniotomy twice with drainage and empiric antibiotic therapy. In our case, neutropenia was present as an immunodeficiency, which made bacteremia severe. There has not been reported a case of septic emboli of three lesions; skin, lung, and brain. C. striatum bacteremia may result in septic emboli and should immediately be treated with antibiotics.

Dexamethasone therapy versus surgery for chronic subdural haematoma (DECSA trial): study protocol for a randomised controlled trial

BackgroundChronic subdural haematoma (CSDH) is a common neurological disease with a rapidly rising incidence due to increasing age and widespread use of anticoagulants. Surgical intervention by burr-hole craniotomy (BHC) is the current standard practice for symptomatic patients, but associated with complications, a recurrence rate of up to 30% and increased mortality. Dexamethasone (DXM) therapy is, therefore, used as a non-surgical alternative but considered to achieve a lower success rate. Furthermore, the benefit of DXM therapy appears much more deliberate than the immediate relief from BHC. Lack of evidence and clinical equipoise among caregivers prompts the need for a head-to-head randomised controlled trial. The objective of this study is to compare the effect of primary DXM therapy versus primary BHC on functional outcome and cost-effectiveness in symptomatic patients with CSDH.Methods/DesignThis study is a prospective, multicentre, randomised controlled trial (RCT). Consecutive patients with a CSDH with a Markwalder Grading Scale (MGS) grade 1 to 3 will be randomised to treatment with DXM or BHC. The DXM treatment scheme will be 16 mg DXM per day (8 mg twice daily, days 1 to 4) which is then halved every 3 days until a dosage of 0.5 mg a day on day 19 and stopped on day 20. If the treatment response is insufficient (i.e. persistent or progressive symptomatology due to insufficient haematoma resolution), additional surgery can be performed. The primary outcomes are the functional outcome by means of the modified Rankin Scale (mRS) score at 3 months and cost-effectiveness at 12 months. Secondary outcomes are quality of life at 3 and 12 months using the Short Form Health Survey (SF-36) and Quality of Life after Brain Injury Overall Scale (QOLIBRI), haematoma thickness after 2 weeks on follow–up computed tomography (CT), haematoma recurrence during the first 12 months, complications and drug-related adverse events, failure of therapy within 12 months after randomisation and requiring intervention, mortality during the first 3 and 12 months, duration of hospital stay and overall healthcare and productivity costs. To test non-inferiority of DXM therapy compared to BHC, 210 patients in each treatment arm are required (assumed adjusted common odds ratio DXM compared to BHC 1.15, limit for inferiority < 0.9). The aim is to include a total of 420 patients in 3 years with an enrolment rate of 60%.DiscussionThe present study should demonstrate whether treatment with DXM is as effective as BHC on functional outcome, at lower costs.Trial registrationEUCTR 2015-001563-39. Date of registration: 29 March 2015.

Effects of Atorvastatin on Surgical Treatments of Chronic Subdural Hematoma

To investigate the effects of atorvastatin on the surgical treatment of patients with chronic subdural hematoma (CSDH). Our retrospective study included 245 consecutive adult patients undergoing burr-hole craniotomy for CSDH. Data included baseline characteristics and recurrence, postoperative complications, and mortality. Univariate and multivariate regression models analyzed the association between administration of atorvastatin perioperatively and recurrence rates. Multivariate analysis showed perioperative atorvastatin administration (odds ratio [OR] 0.336; P=0.039), diabetes mellitus (OR 3.949, P= 0.010), and GCS of 15 preoperatively (OR 0.197; P= 0.020) to be significantly related to recurrence risk. Postoperative complications and mortality did not significantly differ between patients with and those without atorvastatin therapy. Our findings demonstrate that the administration of atorvastatin perioperatively is associated with a lower risk of CSDH recurrence rate. The use of atorvastatin perioperatively was not associated with higher rates of morbidity or mortality.

Randomized controlled study on the curative effects of twist-drill craniotomy and burr-hole craniotomy in the treatment of chronic subdural hematoma.

The present randomized controlled study investigated the differences in the curative effects of twist-drill craniotomy (TDC) and burr-hole craniotomy (BHC) in the treatment of chronic subdural hematoma (CSDH). A total of 40 patients diagnosed with CSDH via head computed tomography (CT) who required surgical decompression from January 2016 to January 2017 were enrolled in the present study, and were randomly divided into a TDC group (n=20) and a BHC group (n=20). The modified Rankin scale (mRS) scores of patients were recorded prior to the operation, and at 48 h and 3 months after the operation. The differences in the mRS score (VmRS) among the groups were calculated using the Mann-Whitney U test. The 40 patients enrolled comprised 33 males and 7 females, and there were no significant differences in the general clinical characteristics between the two groups. In the BHC group, 3 patients had a pre-operative mRS score of 5 points, among which 2 cases died at 32 and 45 days after discharge. In the TDC group, 4 patients had a pre-operative mRS score of 5 points, among which 1 case died of epilepsy and pulmonary infection at 1 month after the operation. No difference in the mortality rate was present between the two groups. During the 3-month follow-up, head CT indicated that the intracranial hematoma in a total of 4 patients, including 3 cases in the TDC group and 1 case in the BHC group, completely disappeared. In the BHC group, 3 cases required a repeated incision and drainage after the first operation, while no secondary operation was required in any of the cases of the TDC group. The average length of stay at the hospital (LOS) after TDC was 9.00±2.91 days, which was significantly shorter than that after BHC (14.75±5.95 days). In the total sample of 40 patients, a longer LOS was associated with a higher risk of secondary operation due to recurrence after discharge. The variation value of the mRS score at 3 months after the operation and its ratio vs. the pre-operative score in the TDC group were significantly different from those in the BHC group, suggesting that the improvement of neurological function after TDC was significantly greater than that after BHC. Although 18 patients (90%) in the TDC group were cured, there was no significant difference from the cure rate in the BHC group [15 patients (75%)]. In conclusion, no significant differences were identified in the cure rate and the mortality rate of patients with CSDH after the two types of surgical treatment. However, the mRS score in the TDC group at 3 months after the operation exhibited a significantly greater improvement compared with that in the BHC group, and the overall LOS in the TDC group was significantly shorter than that in BHC group. Therefore, TDC is superior to BHC in the treatment of CSDH (trial registration no. ChiCTR-INR-16008368).