cSDH Recurrence Research Articles

Safety of Antithrombotic Resumption in Chronic Subdural Hematoma Patients with Middle Meningeal Artery Embolization: A Case Control Study

ObjectiveChronic subdural hematoma (CSDH) is a serious problem with an incidence of 20.6/100,000/year in North America and is posited to grow as the population ages. Middle Meningeal Artery (MMA) embolization is an upcoming therapy for treatment of CSDH. Among patients with CSDH who undergo MMA embolization outcomes are no different in patients who resume the antithrombotic (AT) after MMA embolization as compared to patients who don't resume AT. MethodsWe did retrospective review of all cases of MMA embolization in the setting of CSDH done over 2.5 years in 2 centers. Comparison of cases in which AT was resumed vs controls with no AT was performed. A successful outcome was defined as reduction of at least 50% volume in CSDH. Univariate analysis regarding all outcome measures for baseline variables was performed using Fisher exact test or t-test. Multivariate logistic regression with controlling for age, surgical evacuation of the hematoma. ResultsThere were a total of 56 MMA embolization cases, 33 of them had no AT started and 23 of them had AT resumption at a mean of 2.4 days. About 40% of patients had surgical evacuation done prior to MMA embolization. There was no significant difference in hematoma reduction or volume even after adjusting for surgical evacuation (OR 1.00 95%CI 0.60- 1.67). Patients who had AT resumption had more CAD (71%vs 21% p= 0.001) and Afib (58% vs 18% p=0.002) necessitating AT. ConclusionAT therapy can be safely resumed in CSDH after MMA embolization as there is no significant difference in CSDH volume reduction and recurrence.

Perioperative prophylactic middle meningeal artery embolization for chronic subdural hematoma: a series of 44 cases.

Chronic subdural hematoma (cSDH) is a common and challenging pathology to treat due to both the historically high recurrence rate following surgical evacuation and the medical comorbidities inherent in the aging patient population that it primarily affects. Middle meningeal artery (MMA) embolization has shown promise in the treatment of cSDHs, most convincingly to avoid surgical evacuation in relatively asymptomatic patients. Symptomatic patients requiring surgical evacuation may also benefit from perioperative MMA embolization to prevent cSDH recurrence. The goal of this study was to determine the utility of perioperative MMA embolization for symptomatic cSDH requiring surgical evacuation and to assess if there is a decrease in the cSDH recurrence rate compared to historical recurrence rates following surgical evacuation alone. Symptomatic cSDHs were evacuated using a subdural evacuating port system (SEPS) with 5-mm twist-drill craniostomy in an intensive care unit or by performing a craniotomy in the operating room, using either a small (silver dollar, < 4 cm) or large (≥ 4 cm) craniotomy. MMA embolization was performed perioperatively using angiography, selective catheterization of the MMA, and infusion of polyvinyl particles. Outcomes were assessed clinically and radiographically with interval head CT imaging. There were 44 symptomatic cSDHs in 41 patients, with 3 patients presenting with bilateral symptomatic cSDH. All cSDHs were evacuated using an SEPS (n = 18), a silver-dollar craniotomy (n = 16), or a large craniotomy (n = 10). Prophylactic MMA embolization was performed successfully in all cSDHs soon after surgical evacuation. There were no deaths and no procedural complications. There was an overall reduction of greater than 50% or resolution of cSDH in 40/44 (90.9%) cases, regardless of the evacuation procedure used. Of the 44 prophylactic cases, there were 2 (4.5%) cases of cSDH recurrence that required repeat surgical evacuation at the 1-year follow-up. These 2 cSDHs were initially evacuated using an SEPS and subsequently required a craniotomy, thereby representing an overall 4.5% recurrence rate of treated cSDH requiring repeat evacuation. Most notably, of the 26 patients who underwent surgical evacuation with a craniotomy followed by MMA embolization, none had cSDH recurrence requiring repeat intervention. Perioperative prophylactic MMA embolization in the setting of surgical evacuation, via either craniotomy or SEPS, may help to lower the recurrence rate of cSDH.

Preoperative neutrophil to Lymphocyte Ratio as a predictor of Chronic Subdural Hematoma recurrence

IntroductionChronic subdural hematoma (CSDH) is a common pathology with a recurrence rate ranging from 2 to 37%. Recently, several studies have suggested the possible relationship between the increase in Neutrophil to Lymphocyte Ratio (NLR) and the poor outcome of different pathologies. The aim of this study is to investigate the potential correlation between the pre-operative NLR value and the risk of CSDH recurrence. MethodsFrom January 2015 to December 2019, 261 CSDH patients were surgically treated at our Department. Data regarding patients' baseline characteristics and their hematologic parameters were retrospectively collected from medical records, while the maximum thickness of the hematoma was measured on pre-operative CT scans. Patients with concomitant cerebrovascular, infective, inflammatory, haematological, or neoplastic diseases, INR > 1.5, previous craniotomy, ventriculoperitoneal or ventriculo-atrial shunt or missing data were excluded from the study.Minimum and maximum follow-up were 4 months and 3 years respectively. ResultsA total of 104 patients were enrolled in this study. Mean age was 77.5 ± 14.1 and 77.2 ± 14.2 years respectively in the non-recurrence and recurrence groups (p value, 0.924). Preoperative maximum hematoma thickness resulted 2.2 ± 0.5 cm in patients without recurrence and 2.4 ± 0.6 cm in those with CSDH recurrence (p value, 0.113). Mean pre-operative NLR was higher (12.7 ± 10.4 vs 6.3 ± 4.8) in the recurrence group than in the non-recurrence one. This difference resulted significant (p value, 0.001) at statistical analysis. ConclusionsPre-operative NLR is an easily obtainable marker, which may be helpful in clinical practice to stratify the risk of CSDH recurrence.

Abstract 1122‐000082: Outcomes of Chronic and Subacute Subdural Hemorrhages Treated with Middle Meningeal Artery Embolization

Introduction : Chronic subdural hematoma (cSDH) is a common neurosurgical condition with a high recurrence rate. Middle meningeal artery (MMA) embolization has been shown to reduce the incidence of re‐bleeding and prevent recurrence of cSDH by devascularizing the subdural membranes and shifting the balance from continued leakage and accumulation of blood and proteinaceous material to reabsorption. We report our single center experience of MMA embolization for treatment of chronic and subacute subdural hematoma. Methods : We performed a retrospective chart review of all patients ≥18 years who underwent MMA embolization between 01/01/2020‐03/01/2021 for cSDH. We looked at the outcomes, rate of recurrence and possible complications after MMA embolization. A descriptive analysis for continuous and categorical variables was performed using SAS 9.4 version. Results : A total of 41 MMA embolizations were performed on 32 patients with a median age of 75 (Q1‐Q3 70–83). Median hematoma thickness was 12 mm. Among them, 52% patients underwent particle embolization while 48% underwent liquid embolization. One patient had recurrence on follow up imaging and required drainage with burr hole. Three patients underwent hematoma evacuation after MMA embolization without evidence of recurrence on imaging. Three cases were aborted due to high risk or difficult access. There were no procedure related complications in the whole study population. 65% patient achieved mRS 0–2 on 90 day follow up visit. There was no significant difference between particles and liquid embolizations. Conclusions : Middle meningeal artery embolization could be used as a safe and effective intervention for prevention of recurrence and improving outcomes of subacute or chronic subdural hematoma.

Middle Meningeal Artery Embolization Versus Conventional Treatment of Chronic Subdural Hematomas.

Middle meningeal artery (MMA) embolization is an emerging minimally invasive endovascular technique for chronic subdural hematoma (cSDH). Currently, limited literature exists on its safety and efficacy compared with conventional treatment (open-surgical-evacuation-only). To compare MMA embolization to conventional treatment. Retrospective analysis of patients with cSDHs treated with MMA embolization in a single center from 2018 to 2019 was performed. Comparisons were made with a historical conventional treatment cohort from 2006 to 2016. Propensity score matching analysis was used to assemble a balanced group of subjects. A total of 357 conventionally treated cSDH and 45 with MMA embolization were included. After balancing with propensity score matching, a total of 25 pairs of cSDH were analyzed. Comparing the embolization with the conventional treatment group yielded no significant differences in complications (4%vs 4%; P>.99), clinical improvement (82.6%vs 83.3%; P=.95), cSDH recurrence (4.3%vs 21.7%; P=.08), overall re-intervention rates (12%vs 24%; P=.26), modified Rankin scale >2on last follow-up (17.4%vs 32%; P=.24), as well as mortality (0%vs 12%; P=.09). Radiographic improvement at last follow-up was significantly higher in the open surgery cohort (73.9%vs 95.6%; P=.04). However, there was a trend for lengthier last follow-up for the historical cohort (72vs 104 d; P=.07). There was a trend for lower recurrence and mortality rates in the embolization era cohort. There were significantly higher radiological improvement rates on last follow-up in the surgical only cohort era. There were no significant differences in complications and clinical improvement.

Derivation of a Clinical Score for Prediction of Recurrence Following Evacuation of Chronic Subdural Hematoma: A Retrospective Cohort Study at a National Referral Centre

Chronic subdural hematoma (cSDH) is a common pathology, and recurrence is a common complication, which may be predicted by certain patient and radiologic factors. Empiric radiologic surveillance has been shown to convey no benefit. A retrospective review of a prospectively collated database was performed. Preoperative and postoperative noncontrast computed tomography scans were reviewed. Radiologic appearance, preoperative hematoma volume, patient age, presence of bilateral hematomas, maximal hematoma thickness, and therapeutic coagulopathy were assessed as predictors. Receiver operating characteristic curve analysis, logistic regression, and LASSO regression were used to select potential predictors. A multivariate model was then fitted, and a score was derived. A total of 142 patients were included. Maximal hematoma thickness >12 mm (P= 0.02) and age >65 years (P= 0.01) were found to correlate with the likelihood of recurrence. Bilateral hematomas and a hyperdense or mixed density appearance were also identified on LASSO regression. Bilateral hematomas (P= 0.19), hyperdense or mixed density (P= 0.66), maximum thickness >12 mm (P= 0.01), and age >65 years (P= 0.02) were included in the multivariate model. A 6-point score was derived. A score of>3 had a sensitivity of 89% (95% confidence interval [CI] 78%-97%) and specificity of 26% (95% CI, 17%-34%) for predicting recurrence, with recurrence significantly more likely in patients with a score of 4-6 versus those with a score of 0-3 (P= 0.02). Certain radiologic findings may predict the recurrence of cSDH following evacuation. The score derived may be useful in identifying patients who might benefit from routine postoperative surveillance imaging.

Surgery of chronic subdural hematoma under local anesthesia and its association with recurrence: A single tertiary care center experience

ObjectiveChronic subdural hematoma (CSDH) surgery is like other neurosurgical procedures in terms of its potential for major morbidities, especially recurrence, which may mandate further surgeries. An extremely limited number of studies have looked at the type of anesthesia and its association with recurrence. In fact, most of the studies that exist are focused on the safety of local anesthesia in minimizing potential cardiac and respiratory complications, rather than looking at recurrence as an outcome. This study aimed to evaluate the association between the type of anesthesia and the recurrence of CSDH. MethodsA hospital-based case series study of combined prospective and retrospective nature was conducted on 88 patients who had undergone surgical care for CSDH during the period from January 2016 through December 2018 in the neurosurgery department of Aseer Central Hospital, Abha, Saudi Arabia. ResultsA total of 88 patients were included in the study. The median age was 70 years, and most patients (62%) had one or more comorbid disease(s), 47 (53.4%) underwent general anesthesia for CSDH surgery, whereas 41 (46.6%) underwent local anesthesia (LA). Recurrence within 3 months was seen in 12 patients (13.6%). Univariable regression analysis revealed that the risk of recurrence was four times more when surgery was performed under LA. ConclusionsThe study is the first in the English literature to conclude that drainage of CSDH under LA is associated with a higher recurrence rate; however, the authors remain neutral and recommend individualization of treatment options based on the patient’s status. Local anesthesia may be safer in terms of postoperative anesthetic complications, but it carries a higher rate of recurrence. Further well-designed randomized studies are required.

The Mini-Craniotomy for cSDH Revisited: New Perspectives.

Background: Chronic subdural hematomas (cSDH) are increasingly prevalent worldwide with the increased aging population and anticoagulant use. Different surgical, medical, and endovascular treatments have had varying success rates. Primary neurosurgical interventions include burr hole drainage of the cSDH and mini-craniotomies/craniotomies with or without fenestration of the inner membrane. A key assessment of the success or failure of cSDH treatments has been symptomatic recurrence rates which have historically ranged from 5 to 30%. Pre-operative prediction of the inner subdural membrane by CT scan was used to guide our decision to perform mini-craniotomies. Release of the inner membrane facilitates the expansion of the brain and likely improves glymphatic flow.Methods: Consecutive mini-craniotomies (N = 34) for cSDH evacuation performed by a single neurosurgeon at a quaternary academic medical center/Level I trauma center from July 2018-September 2020 were retrospectively reviewed. Patient characteristics [age, gender, presenting GCS, GOS, initial CTs noting the inner subdural membrane, midline shift (MLS), cSDH width, inner membrane fenestration, cSDH recurrence, post-operative seizures, infections, length of stay] were extracted from the EMR.Results: Twenty nine patients had mini-craniotomies as primary treatment of the cSDH. Mean age = 68.9 ± 19.7 years (range 22–102), mean pre-operative GCS = 14.5 ± 1.1, mean MLS = 6.75 ± 4.2 mm, and mean maximum thickness of cSDH = 17.7 ± 6.0 mm. Twenty four were unilateral, five bilateral, 34 total craniotomies were performed. Thirty three had inner membrane signs on pre-operative head CTs and an inner subdural membrane was fenestrated in all cases except for the one craniotomy that didn't show these characteristic CT findings. Mean operating time = 79.5 ± 26.0 min. Radiographic and clinical improvement occurred in all patients. Mean improvement in MLS = 3.85 ± 2.69. There were no symptomatic recurrences, re-operations, surgical site infections, or deaths during the 6 months of follow-up. One patient was treated for post-operative seizures with AEDs for 6 months.Conclusion: Pre-operative CT scans demonstrating inner subdural membranes may guide one to target the treatment to allow release of this tension band. Mini-craniotomy with careful fenestration of the inner membrane is very effective for this. Brain re-expansion and re-establishment of normal brain interstitial flow may be important in long term outcomes with cSDH and may be related to the recent interests in brain glymphatics and dural lymphatics.

Influence of Antiplatelet and Anticoagulant Drug Use on Outcomes after Chronic Subdural Hematoma Drainage.

We aim to describe the outcomes after chronic subdural hematoma drainage (CSDH) management in a large cohort of patients on antithrombotic drugs, either antiplatelets or anticoagulants, at presentation and to inform clinical decision making on the timing of surgery and recommencement of these drugs. We used data from a previous UK-based multi-center, prospective cohort study. Outcomes included recurrence within 60 days, functional outcome at discharge, and thromboembolic event during hospital stay. We performed Cox regression on recurrence and multiple logistic regression on functional outcome. There were 817 patients included in the analysis, of which 353 (43.2%) were on an antithrombotic drug at presentation. We observed a gradual reduction in risk of recurrence for patients during the 6 weeks post-CSDH surgery. Neither antiplatelet nor anticoagulant drug use influenced risk of CSDH recurrence (hazard ratio, 0.93; 95% confidence interval [CI], 0.58–1.48; p = 0.76) or persistent/worse functional impairment (odds ratio, 1.08; 95% CI, 0.76–1.55; p = 0.66). Delaying surgery after cessation of antiplatelet drug did not affect risk of bleed recurrence. There were 15 in-hospital thromboembolic events recorded. Events were more common in the group pre-treated with antithrombotic drugs (3.3%) compared to the non-antithrombotic group (0.9%). Patients on an antithrombotic drug pre-operatively were at higher risk of thromboembolic events with no excess risk of bleed recurrence or worse functional outcome after CSDH drainage. The data did not support delaying surgery in patients on antithrombotic therapy. In the absence of a randomized controlled trial, early surgery and early antithrombotic recommencement should be considered in those at high risk of thromboembolic events.

The effect of atorvastatin on recurrence of chronic subdural hematoma after novel YL-1 puncture needle surgery

ObjectiveChronic subdural hematoma (CSDH) is a common neurological disorder with a high recurrence rate. This study investigates the effect that atorvastatin has when used as a postoperative adjuvant therapy on the prevention of CSDH recurrence after YL-1 puncture needle surgery. Patients and methodsA retrospective analysis of 516 CSDH patients who underwent YL-1 puncture needle surgery was undertaken. Baseline characteristics including sex, age, history of injury, past medical histories (anticoagulation, liver dysfunction, heart diseases, malignant tumors, diabetes, hemodialysis, and chronic alcoholism), and computed tomography (CT) or magnetic resonance imaging (MRI) diagnostic indicators (bilateral, mixed density or signal, maximum hematoma width, and brain atrophy) were recorded. Differences in recurrence rates were compared between two groups: one with atorvastatin after surgery and one without. Results516 patients (429 men and 87 women), aged 14–98 years (mean age, 67.09 ± 11.74 years) were included in the study. YL-1 puncture needle surgery was performed 610 times. 94 patients had bilateral surgery, totaling 184 procedures. 301 patients with 360 procedures were treated with atorvastatin after surgery, of which 25 had recurrent CSDH; recurrence rate: 7.0 % (25/360). 215 patients with 250 procedures had surgery without subsequent atorvastatin, of which 14 had recurrent CSDH; recurrence rate: 5.6 % (14/250). Univariate analysis indicated no statistically significant difference in recurrence rates between groups (P > 0.05). Baseline characteristics of the two groups (age, sex, history of injury, past medical histories, CT or MRI diagnostic indicators) also showed no statistical difference (all P > 0.05). ConclusionsYL-1 puncture needle surgery with irrigation and closed-system drainage is an effective surgical treatment for CSDH. Atorvastatin has no statistically significant effect on the prevention of CSDH recurrence after surgery.

Middle Meningeal Artery Embolization for Chronic Subdural Hematoma: A Multi-Center Experience of 154 Consecutive Embolizations.

Middle meningeal artery (MMA) embolization has emerged as a promising treatment for chronic subdural hematoma (cSDH). To determine the safety and efficacy of MMA embolization. Consecutive patients who underwent MMA embolization for cSDH (primary treatment or recurrence after conventional surgery) at 15 centers were included. Clinical details and follow-up were collected prospectively. Primary clinical and radiographic outcomes were the proportion of patients requiring additional surgical treatment within 90 d after index treatment and proportion with>50% cSDH thickness reduction on follow-up computed tomography imaging within 90 d. National Institute of Health Stroke Scale and modified Rankin Scale were also clinical outcomes. A total of 138 patients were included (mean age: 69.8, 29% female). A total of 15 patients underwent bilateral interventions for 154 total embolizations (66.7% primary treatment). At presentation, 30.4% and 23.9% of patients were on antiplatelet and anticoagulation therapy, respectively. Median admission cSDH thickness was 14 mm. A total of 46.1% of embolizations were performed under general anesthesia, and 97.4% of procedures were successfully completed. A total of 70.2% of embolizations used particles, and 25.3% used liquid embolics with no significant outcome difference between embolization materials (P>.05). On last follow-up (mean 94.9 d), median cSDH thickness was 4 mm (71% median thickness reduction). A total of 70.8% of patients had >50% improvement on imaging (31.9% improved clinically), and 9 patients (6.5%) required further cSDH treatment. There were 16 complications with 9 (6.5%) because of continued hematoma expansion. Mortality rate was 4.4%, mostly unrelated to the index procedure but because of underlying comorbidities. MMA embolization may provide a safe and efficacious minimally invasive alternative to conventional surgical techniques.

Predictive Factors for Chronic Subdural Hematoma Recurrence

Abstract Background: Recurrence of chronic subdural hematoma is a major impact on the clinical course during management. Literatures define several factors during their study. Aim of Study: We aimed to investigate the predictive factors that may be responsible for CSDH recurrence in patients who underwent surgical evacuation at our center. Patients and Methods: This was a retrospective analysis of medical records for patients who underwent surgical evac-uation of CSDH at Kasr Al-Ainy University Hospital from July 2018 to August 2020. The diagnosis of CSDH was established by Computed Tomography (CT). The ethical approval was gained prior to data retrieval. The main inclusion criteria is the presence of CSDH on CT scan with neurological sequelae. It has been found that 54 medical records. Eleven cases were excluded from the study sample due to missing data. Finally, 43 patients' file were reviewed for analysis. Routine imaging of post-operative evacuation is achieved in the 1st day, 1st and 3rd months. Results: The mean and standard deviation of age was 64.71±12.65 years, age range 45-88 years. The male patients constituted 76.7% the interval between head trauma (found in 39.5%) and surgery was up to 60 days. Multivariate analysis identified mixed density as the sole predictive value for recurrence (OR=16.8, 95% CI=13.4-20.2, p-value=0.021). Conclusion: Recurrence of an evacuated chronic subdural hematoma is not uncommon phenomena. Presence of acute blood on top of chronic fluid (mixed density) is regarded as a risk factor for recurrence in the first month post-operatively.

Elevated blood urea nitrogen is associated with recurrence of post-operative chronic subdural hematoma

BackgroundChronic subdural hematoma (CSDH) is fundamentally treatable with about a 2–31% recurrence rate. Recently, there has been renewed interest in the association between Blood Urea Nitrogen (BUN) and intracranial lesion. Therefore, this paper attempts to show the relationship between BUN and CSDH recurrence.MethodsA total of 653 CSDH cases with Burr-hole Irrigation (BHI) were enrolled from December 2014 to April 2019. The analyzed parameters included age, gender, comorbidities, laboratory investigations, medication use and hematoma location. The cases were divided into recurrence and non-recurrence groups while postoperative BUN concentration was further separated into quartiles (Q1 ≤ 4.0 mmol/L, 4.0 < Q2 ≤ 4.9 mmol/L, 4.9 < Q3 ≤ 6.4 mmol/L, Q4 > 6.4 mmol/L). Restricted cubic spline regressions and logistic regression models were performed to estimate the effect of BUN on CSDH recurrence.ResultsCSDH recurrence was observed in 96 (14.7%) cases. Significant distinctions were found between recurrence and non-recurrence groups in postoperative BUN quartiles of cases (P = 0.003). After adjusting for the potential confounders, the odds ratio of recurrence was 3.069 (95%CI =1.488–6.330, p = 0.002) for the highest quartile of BUN compared with the lowest quartile. In multiple-adjusted spline regression, a high BUN level visually showed a significantly high OR value of recurrence risk.ConclusionsElevated BUN at post-operation is significantly associated with the recurrence of CSDH, and it is indicated that high levels of serum BUN after evacuation may serve as a risk factor for CSDH recurrence.

Risk-assessment in chronic subdural hematoma evaluated in 148 patients - A score for predicting recurrence

BackgroundChronic subdural hematoma (CSDH) is a frequent disease in neurosurgical practice. However, a considerable recurrence rate keeps this condition challenging to treat. We aimed to provide a simple tool for risk assessment in these patients. MethodsWe conducted a retrospective analysis of surgically treated patients with chronic subdural hematomas. In addition to patients’ demographics, radiological assessment included volume, thickness, midline shift and density of hematomas. Statistically significant variables in univariate analysis were further analyzed in a multivariate logistic regression model to create a risk score for recurrence of CSDH. ResultsA total of 148 patients were identified and included for analysis. 50.7 % (n = 75) were older than 76 years of age. The overall hematoma recurrence rate requiring surgery was 23.6 % (n = 35). Preoperative thrombocytopenia, postoperative midline shift >6 mm, hematoma volume >80 mL and overall hematoma density >45 Hounsfield Units (HU), were significantly more frequent in the recurrence group. Furthermore, after multivariate assessment, postoperative hematoma density and volume were independent risk factors and included in the risk assessment tool. Patients were divided into 3 risk groups corresponding to the total scores. ConclusionWe provide a risk-score assessment for predicting recurrence of subdural hematoma. The risk-score comprises postoperative hematoma volume and density. This tool could ease decision making in follow-up evaluation and indication for recurrence surgery. Yet, further prospective evaluation is required to assess the clinical value of this tool.

Finnish study of intraoperative irrigation versus drain alone after evacuation of chronic subdural haematoma (FINISH): a study protocol for a multicentre randomised controlled trial

IntroductionChronic subdural haematomas (CSDHs) are one of the most common neurosurgical conditions. The goal of surgery is to alleviate symptoms and minimise the risk of symptomatic recurrences. In the past,...

Gradation density hematoma is a predictor of chronic subdural hematoma recurrence associated with inflammation of the outer membrane

ObjectivesChronic subdural hematoma (CSDH) is a common form of intracranial hemorrhage with a high recurrence rate. This study aimed to determine the CSDH recurrence rate associated with preoperative computed tomography (CT) findings and the pathological examination of the dura and the outer membrane. Patients and MethodsWe retrospectively reviewed the medical records of patients with CSDH who underwent surgery in our hospital between May 2010 and November 2019. CSDHs were classified into four groups according to the hematoma density on CT: low-density hematoma (LDH), gradation-density hematoma (GDH), iso-density-hematoma (IDH), and mixed-density hematoma (MDH). The postoperative recurrence rate was calculated for each group, and we examined whether the recurrence rate correlated with the CT findings. We also took samples of the dura to analyze inflammatory cell infiltration and the blood vessels. ResultsA total of 388 patients were analyzed. The total recurrence rate was 13.7%. CT findings at admission showed LDH in 50, GDH in 136, IDH in 110, and MDH in 92 patients. The recurrence rate of GDH (23.5%, 32/136) was comparable to the rate of the other CSDH types (11.5%, 61/388). Univariate and multivariate analyses found GDH to be an independent risk factor for the recurrence of CSDH. GDH patients displayed much more angiogenesis and inflammatory cell infiltration in the outer membrane and the dura. ConclusionGDH is an independent predictor for CSDH recurrence. The presence of inflammation in GDH might be the primary cause of CSDH recurrence.

New tools in percutaneous minimally invasive chronic subdural hematomas evacuation

BackgroundIncidence of chronic subdural hematomas (cSDH) is expected to progressive rise in the next decades. There is no univocal indication of the approach to be used. Furthermore, there is no data about the efficacy of twist drill craniostomy (TDC) in hematomas with membranes. ObjectiveTo describe our modified technique for TDC in patients affected by cSDH with membranes and in treatment with antiplatelets. MethodsWe analyzed a group of 37 patients, affected by cSDH with membrane (type D laminar membrane and type G trabecular membrane according to Nakaguchi classification), treated with mushroom TDC using a modified technique. ResultsAfter surgery the average maximum thickness of the common postoperative liquoral subdural collection decreased from 18.8 to 6.21 mm. We documented one acute subdural hematoma (2.7%), asymptomatic and not treated, and one recurrence of cSDH (2.7%) after 2 months that needed re-intervention with single burr hole. ConclusionsWe presented a modified twist drill technique, characterized by the introduction of an application of a new device that optimizes both surgical results, clinical outcome and surgical procedure time. The presence of membrane type D and G does not affect the efficacy of drainage, that is negatively related to the presence of clots or acute hematoma. This modified technique is safe, fast, effective and represents a valid first line treatment of an unstable and unpredictable pathology such as cSDH. We suggest performing such technique on a larger patients’ cohort to further validate its effectiveness.

Subdural Pneumocephalus Aspiration Reduces Recurrence of Chronic Subdural Hematoma.

Chronic subdural hematoma (cSDH) is a common neurosurgical condition, with symptoms ranging from headaches to coma. Operative evacuation is the treatment of choice. Subdural reaccumulation leading to reoperation is a vexing postoperative complication. To present a novel technique for intraoperative aspiration of pneumocephalus via a subdural drain following SDH evacuation as a method of reducing potential subdural space and promoting cerebral expansion, thereby decreasing SDH recurrence. In this retrospective study, 15 patients who underwent operative evacuation of cSDH between 2008 and 2015 were assessed. Six patients underwent a small craniotomy with intraoperative pneumocephalus aspiration. These patients were matched by age, gender, and anticoagulation status to 9 patients who underwent evacuation of SDH without pneumocephalus aspiration. Quantitative volumetric analysis was performed on the preoperative, postoperative, and 1-mo follow-up computed tomography scan to assess the subdural volume. In the immediate postoperative period, there was no difference in the percentage of residual subdural fluid between the aspiration and control groups (0.291 vs 0.251; P=1.00). There was a decrease in amount of pneumocephalus present when the aspiration technique was applied (0.182 vs 0.386; P=.041). At 1-mo follow-up, there was a decrease in the residual cSDH volume between the aspiration and the control groups (28.7 mL vs 60.8 mL; P=.011). The long-term evacuation rate was greater in the aspiration group (75.4% vs 51.6%; P=.015). Intraoperative aspiration of cSDH cavity is a safe technique that may enhance cerebral expansion and reduce likelihood of cSDH recurrence.

Comparative Study of Surgical Outcome of Chronic Subdural Hematoma Treated with and without External Drainage

Background and purpose: Chronic subdural hematoma (cSDH) poses a significant morbidity and mortality risk particularly in elderly population. It can be treated with simple surgical techniques like burr hole drainage under local anesthesia, however it often recurs after surgical evacuation in significant number of patients.&#x0D; Material and methods: A randomized controlled trial was designed at Mayo Hospital/KEMU in 2013 to 2016. Total number of 98 patients who met the inclusion and exclusion criteria were randomized into ‘with drain’ and ‘without drain’ arm. All of them were treated with burr hole drainage under local anesthesia. Half of them had subdural drain while the remaining half did not. Recurrence of hematoma and surgical outcome was compared.&#x0D; Result: Among 98 patients included in the study(54 males and 44 females) met the inclusion criteria. Mean age of presentation was 63 years ± 12.4 (range 40-100). There was left sided preponderance in hematoma location (53.1%). Mean midline shift was 2.7 mm ± 1.5. Owing to drainage of cSDH, post-operative MRC score of patients along with midline shift in the CT brain showed statistically significant improvement. However, irrespective of insertion of drainage system, there was no significant difference noted in recurrence of cSDH, midline shift and improvement in presenting symptoms (hemiparesis or monoparesis) considering all post-operative days.&#x0D; Conclusion: There is no significant difference in recurrence rate depending on weather a postoperative external drainage is placed or not.

Middle meningeal artery embolization as an adjuvant treatment to surgery for symptomatic chronic subdural hematoma: a pilot study assessing hematoma volume resorption

BackgroundChronic subdural hematoma (CSDH) is a common condition requiring surgical treatment; however, recurrence occurs in 15% of cases at 1 year. Middle meningeal artery (MMA) embolization has recently emerged as...