Development Of Chronic Subdural Hematoma Research Articles

Preservation of the middle meningeal artery during unruptured aneurysm surgery: an independent risk factor for postoperative chronic subdural hematoma.

Although microsurgical clipping for unruptured aneurysms has become safer and more efficient with modern neurosurgical advances, postoperative chronic subdural hematoma (CSDH) persists as an underrecognized complication. This study investigated the association between preservation of the anterior branch of the middle meningeal artery (MMA) during surgery and CSDH development. We retrospectively reviewed 120 patients who underwent clipping for unruptured aneurysms at Kyungpook National University Chilgok Hospital between May 2020 and July 2023. We evaluated the patients on the basis of surgical approach-lateral supraorbital (LSO) or standard pterional craniotomy-and the status of the MMA postoperatively. We employed pre-and post-operative MR angiography to assess MMA preservation and used follow-up computed tomography scans to monitor CSDH development. Of the 120 patients, 22 (18.3%) developed CSDH. Univariate analysis revealed that male sex, advanced age, and MMA preservation are risk factors for postoperative CSDH. Multivariate analysis supported these findings, indicating a significant association with the development of CSDH. MMA preservation was reported in 65 patients, of whom 60 and 5 underwent LSO and pterional craniotomy, respectively. Preservation of the anterior branch of the MMA during unruptured aneurysm surgery is a risk factor for postoperative CSDH development. Advanced age and male sex also contribute to the increased risk. These findings highlight the need for further investigation into surgical techniques that could mitigate postoperative CSDH development.

Evaluation of Peripheral Blood Inflammatory Markers in Patients with Chronic Subdural Hematoma.

Chronic subdural hematoma (CSH) refers to intracranial hemorrhages frequently caused by minor head trauma and is mostly seen in middle and advanced age. One of the hypotheses regarding the development of CSH is that the inflammatory cascade plays a pivotal role in this process. The inclusion criteria covered patients in all ages who were diagnosed as CSH by computed tomography and/or magnetic resonance imaging and treated by surgical intervention in our clinic between 2018 and 2020. Patient files were reviewed retrospectively, and medical records of age, gender, trauma history, unilateral or bilateral lesion, and leukocyte, neutrophil, lymphocyte, monocytes, and platelet counts were obtained. Receiver operating characteristic (ROC) analysis was used for the most appropriate neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), and age discrimination in the presence of CSH, and multiple logistic regression analyses were used to determine the effect of independent factors on dependent variables. A total of 68 cases, 57 (83.8%) male and 11 (16.2%) female, aged between 13 and 93, were included in the study. The mean age of the patients included in the study was 72.59 ± 13.13 years. NLR of the cases ranged from 1.37 to 34.18, with a mean of 6.53 ± 6.74 and a median of 3.57. NLR and PLR were found to be statistically significantly higher in CSH patients compared to the healthy control group, and the cut-off values for NLR, PLR, and age were 2.8, 132, and 55, respectively. Age and NLR were found to be independent factors associated with CSH (P < 0.05). As seen from the results of this study, peripheral blood values in CSH patients may be significantly higher than in the healthy control group, while they are below the normal laboratory cut-off values.

Resolution of arachnoid cyst after development of chronic subdural hematoma and burr hole surgery - a case report

&lt;p&gt;蜘蛛膜囊腫是先天性且通常無症狀的顱內病灶，自行消失的案例非常罕見，已知有此病灶的病人較一般人於輕微頭部創傷後引發後續的慢性硬腦膜下血腫，若造成腦部壓迫之症狀，臨床上通常會進行顱骨鑽孔引流手術，只引流血水並不會去特別處理囊腫，但在極少數情況下，囊腫會在術後追蹤時被發現慢慢消失。我們報告一例蜘蛛膜囊腫在接受硬性硬腦膜下出血手術後消退的案例，探討其可能的病生理機轉和相關文獻回顧。&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;&lt;p&gt;Arachnoid cyst (AC) is usually asymptomatic, incidentally-found, and a well-known risk factor of developing chronic subdural hematoma (CSDH) after minor head injury in young patients. Spontaneous remission or rupture of arachnoid cyst is very rare. When chronic subdural hematoma occurs, burr hole drainage is indicated if mass effect presenting. Only the hematoma is drained, where the cyst is left untouched. Although the chance of an arachnoid cyst to disappear is low, here we presents a case where the AC disappears after burr hole operation. We subsequently discuss the possible pathophysiological mechanisms and the relevant literatures.&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;

Incidence of and risk factors for chronic subdural hematoma after endoscopic endonasal surgery: quantitative analysis of pneumocephalus.

Chronic subdural hematoma (CSDH) is known to occur after endoscopic endonasal surgery (EES); however, the detailed clinical picture remains unclear. In this study, the authors aimed to examine the incidence of and risk factors for post-EES CSDH, with a focus on the quantitative evaluation of postoperative pneumocephalus. The authors retrospectively collected data on consecutive patients who, between November 2016 and December 2022, had undergone EES during which intraoperative cerebrospinal fluid (CSF) leakage occurred. Using CT images obtained immediately after surgery (CT0), the authors measured the extent of pneumocephalus in detail. The locations of pneumocephalus were divided into two groups: remote and local. Remote pneumocephalus was further subdivided into convexity and ventricular. The incidence of post-EES CSDH was calculated, and its risk factors were analyzed. Among the 159 EES patients included in the study, Esposito grade 1, 2, and 3 intraoperative CSF leakage was confirmed in 22 (14%), 27 (17%), and 110 (69%) patients, respectively. CSDH occurred in 6 patients (3.8%). One patient (0.6%) required unilateral burr hole surgery, whereas the hematomas spontaneously disappeared in the others. All CSDHs occurred in patients with Esposito grade 3 CSF leakage and convexity pneumocephalus on CT0. In the multivariate analysis of 149 sides with convexity pneumocephalus on CT0, the product of the diameter and the thickness of convexity pneumocephalus on CT0 was significantly associated with subsequent CSDH (OR 1.21, 95% CI 1.06-1.38, p = 0.004). Using a cutoff value of 10 cm2, CSDH development could be predicted with a sensitivity of 0.82 and specificity of 0.74. The incidence of post-EES CSDH is acceptably low, and surgery is rarely required. Patients with extensive convexity pneumocephalus on immediate postoperative CT are prone to develop CSDH and thus should be carefully monitored.

Ischaemic Stroke After Chronic Subdural Haematoma: An Uncommon Complication in a Common Disease

Background Chronic subdural haematoma (CSDH) is a common neurosurgical disease, particularly among the elderly, especially those on antiplatelet or anticoagulation with trivial trauma. While anticoagulants/antiplatelets increase the chance of rebleeding in cases of CSDH, discontinuation may increase the risk of stroke in these patients. Case Description We report two cases of CSDH in elderly patients with risk factors who suffered from an ischaemic stroke after undergoing surgery. The first case was an elderly gentleman who had a history of percutaneous coronary intervention, presenting with a CSDH. He developed an anterior cerebral artery infarct in the immediate postoperative period. The second was an elderly gentleman with a history of hypertension presenting with a concomitant left thalamic infarct and large left-sided CSDH. He developed a second middle cerebral artery infarct of the opposite side in the immediate postoperative period. Conclusion The medications used for stroke prophylaxis, that is, antiplatelets and anticoagulants are predisposing factors for the development of CSDH. However, the perioperative period of these patients remains vulnerable to the development of new-onset ischaemic stroke.

Preoperative elevated eosinophils in peripheral blood for prediction of postoperative recurrence of chronic subdural hematoma.

Chronic subdural hematoma (CSDH) is a common neurological disease with a significant postoperative recurrence rate. There are numerous reported studies of the development of CSDH. In recent years, fibrinolysis, angiogenesis, and inflammation have all been identified as relevant factors in the development of CSDH. While several authors have reported risk factors associated with CSDH recurrence, differential blood count of leukocytes has not yet been discussed. Therefore, in this study the authors aimed to retrospectively investigate the association between differential blood leukocyte count and the rate of CSDH recurrence. The authors retrospectively reviewed 476 patients with 529 CSDHs who underwent surgery at a single institution between January 2011 and December 2021. After exclusion of patients who had not undergone a differential blood test of leukocytes preoperatively, CSDHs in 517 cerebral hemispheres of 466 patients were included in the study. Peripheral blood eosinophil counts ≥ 100/µL were considered eosinophil rich. CSDHs in 494 cerebral hemispheres of 445 patients were followed up postoperatively for at least 3 months or until resolution indicated by CSDH disappearance. Postoperative recurrence of CSDH was observed in 46 cerebral hemispheres (9.3%). Among the preoperative differential blood counts of all leukocytes, eosinophils alone were significantly associated with CSDH recurrence (median [IQR] 76/µL [30-155/µL] vs 119/µL [39-217/µL]; p = 0.03). Multivariable regression analysis showed thrombocytopenia (adjusted OR [aOR] 5.23, 95% CI 1.85-14.79; p = 0.002), use of anticoagulant drugs (aOR 2.51, 95% CI 1.17-5.38; p = 0.02), hematoma volume (10 mL per increase) (aOR 1.08, 95% CI 1.00-1.16; p = 0.04), and eosinophil-rich peripheral blood (aOR 2.22, 95% CI 1.17-4.23; p = 0.02) were all independent predictors for CSDH recurrence. This study showed that preoperative peripheral blood eosinophil count was an independent risk factor for CSDH recurrence. Therefore, patients with CSDH who have elevated eosinophils preoperatively in peripheral blood require careful follow-up.

Inflammatory human leucocyte antigen genotypes are not a risk factor in chronic subdural hematoma development.

Chronic subdural hematoma (CSDH) pathophysiology has undergone a paradigm shift from being regarded as solely traumatic to be driven mainly by inflammation. Human leucocyte antigen (HLA) is a gene complex involved in antigen processing and presentation to T lymphocytes, thereby mediating the adaptive immune responses. As specific HLA profiles are associated with inflammatory diseases, patients with a specific HLA profile may have a lower threshold for subdural inflammation, and therefore are predisposed for CSDH development. We hypothesized that (1) CSDH patients have a specific HLA profile compared to a Danish background population, and (2) patients with recurrent CSDH have a specific HLA profile compared to CSDH patients without recurrent CSDH. Three specific HLA class II haplotypes known to drive inflammatory-mediated diseases were determined in 68 patients with CSDH. The distribution of these three haplotypes in our CSDH population was compared to a Danish population of blood donors using Monte Carlo Pearson's chi-square test. Furthermore, the distribution of the haplotypes was compared between CSDH patients with and without recurrent CSDH. We found no significant association between either of the haplotypes and the risk of CSDH, and neither of the haplotypes were associated with increased risk of CSDH recurrence. This study did not show an association between selected HLA class II haplotypes and the risk of CSDH or recurrence of CSDH compared with a healthy background population.

Inflammatory biomarkers differentiate the stage of maturation in chronic subdural hematomas

ObjectiveInflammation is a major pathophysiological driver of the development of chronic subdural hematomas (CSDH), but there is still limited knowledge on the key molecular processes and corresponding biomarkers involved in this disease. In this study, the aim was to study a subset of inflammatory biomarkers and their relation to the clinical status of the patient and the radiological characteristics of the CSDH. MethodsIn this observational study, 58 patients who were operated on with CSDH evacuation, at the Department of Neurosurgery, Uppsala, Sweden, between 2019 and 2021, were prospectively included. The CSDH fluid was collected peri-operatively and was later analyzed with proximity extension assay (PEA) technique (Olink) for a panel of 92 inflammatory biomarkers. Demographic, neurological (Markwalder), radiological (general (Nakaguchi classification) and focal (septa below the burr holes)), and outcome variables were collected. ResultsIn 84 of the 92 inflammatory biomarkers, the concentration was above the detection limit in >50% of the patients. There was a significant difference in GDNF, NT-3, and IL-8 depending on the Nakaguchi class, with higher values in the trabeculated CSDH subtype. In addition, those with septa at the focal area of CSDH collection, had higher levels of GDNF, MCP-3, NT-3, CXCL1, CXCL5, IL8, and OSM. There was no association between Markwalder grade and the inflammatory biomarkers. ConclusionsOur findings support the presence of local inflammation in the CSDH, a shift in biomarker pattern as the CSDH matures towards the trabeculated state, potentially differences in biomarker patterns within the CSDH depending on the focal environment with presence of septa, and that the brain might develop protective mechanisms (GDNF and NT-3) in case of mature and long-standing CSDHs.

Angiogenesis in the Outer Membrane of Chronic Subdural Hematomas through Thrombin-Cleaved Osteopontin and the Integrin α9 and Integrin β1 Signaling Pathways.

A chronic subdural hematoma (CSDH) is considered to be an inflammatory and angiogenic disease. The CSDH outer membrane, which contains inflammatory cells, plays an important role in CSDH development. Osteopontin (OPN) is an extracellular matrix protein that is cleaved by thrombin, generating the N-terminal half of OPN, which is prominently involved in integrin signal transduction. We explored the expression of the N-terminal half of OPN in CSDH fluid and the expression of integrins α9 and β1 and the downstream components of the angiogenic signaling pathways in the outer membrane of CSDHs. Twenty samples of CSDH fluid and eight samples of CSDH outer membrane were collected from patients suffering from CSDHs. The concentrations of the N-terminal half of OPN in CSDH fluid samples were measured using ELISA kits. The expression levels of integrins α9 and β1, vinculin, talin-1, focal adhesion kinase (FAK), paxillin, α-actin, Src and β-actin were examined by Western blot analysis. The expression levels of integrins α9 and β1, FAK and paxillin were also examined by immunohistochemistry. We investigated whether CSDH fluid could activate FAK in cultured endothelial cells in vitro. The concentration of the N-terminal half of OPN in CSDH fluid was significantly higher than that in the serum. Western blot analysis confirmed the presence of these molecules. In addition, integrins α9 and β1, FAK and paxillin were localized in the endothelial cells of vessels within the CSDH outer membrane. FAK was significantly phosphorylated immediately after treatment with CSDH fluid. Our data suggest that the N-terminal half of OPN in CSDH fluid promotes neovascularization in endothelial cells through integrins α9 and β1. The N-terminal half of OPN, which is part of the extracellular matrix, plays a critical role in the promotion of CSDHs.

Acute Traumatic Subdural Hematoma in the Elderly and Associated Factors that May Influence Chronicity.

Traumatic acute subdural hematomas (TASDH) is by far the most common traumatic brain injury in adult patients with blunt trauma, who presented to the Emergency Department (ED). One of the serious sequale of TASDH is the development of Chronic Subdural Hematomas (CSD) with associated deterioration in mental status and convulsion.1,2 Studies to identify the risk factors that favors development of chronicity of TASDH are few and inconclusive. As seen in our prior initial study, there were few factors which were common in those who developed chronicity of their TASDH, and we elected to expand our pool of patients to include those admitted between the years of 2015 and 2021 with ATSDH and identify the common factors associated with development of CSD.

Immunoexpression of MMP-8 and MMP-9 in chronic subdural hematoma.

To determine the possible role of matrix metallopeptidase (MMP)-8 and MMP-9 in the development of chronic subdural hematoma (CSDH), we investigated their expression in CSDH. In our previous study, we analyzed hematoma fluid and peripheral blood of 83 patients with CSDH, including 17 postoperative patients. Based on these results, we included 50 people in the normal group and analyzed 20 markers in the peripheral blood of each person. In order to identify representative markers, it was assessed by using overall differential gene expression. The concentration of MMP-8 was significantly higher in the normal group than that in the preoperative and postoperative groups. The concentration of MMP-9 was significantly lower in the normal group than in both preoperative and postoperative groups. Immunohistochemistry confirmed the expression of MMP-8 and MMP-9 in CSDH membranes. In conclusion, our results provide evidence of the expression of MMP-8 and MMP-9 in CSDH. In addition, the expression of MMP-8 and MMP-9 suggests angiogenesis in CSDH formation.

Випадок нетравматичної субдуральної гематоми

The risk for the development of subacute or chronic subdural hematoma is associated with the widespread use of anticoagulant therapy for both prophylactic and therapeutic purposes. Therefore, the purpose of the study was to carry out clinical and morphological analysis of the case of chronic subdural hematoma associated with the use of antithrombotic therapy to substantiate the pathogenetic links of their relationship. Materials and methods. The case report. The body of a woman with signs of bodily injuries was found in the apartment at the place of residence. The autopsy along the entire length of the vertebral canal revealed a draining thin-layer subdural hemorrhage in the form of layers of liquid dark red blood, which effortlessly filled all the free spaces between the dura mater and arachnoid mater. The bones of the vault, the base and the frontal skeleton of the skull were intact. The dura mater was moderately tense, grayish in color, with the bones of the skull tightly fused in all parts of the skull. On the convex and basal surfaces of both hemispheres of the brain with spread between the hemispheres of the brain, around the cerebellum and trunk with penetration into the large occipital foramen, subdural hemorrhage in the form of layers of thick dark red blood was found. Forensic histological examination of pieces of internal organs revealed hemorrhage under the dura mater of the brain and spinal cord with reactive inflammatory changes, deposition of hemosiderin granules. Forensic toxicological analysis of blood, urine, stomach and small intestine contents, liver and gallbladder and kidneys revealed diclofenac and an unknown substance that might be an anticoagulant; however, it could not be identified by the approved methods due to the limited number of comparison samples. Examination of the corpse in the apartment revealed blisters and ampoules of various drugs in the largest amount of diclofenac, warfarin. Results and discussion. The analysis of the data obtained on the scene, as well as from the medical history, records in the available medical documentation, morphological characteristics of detected hemorrhages, results of forensic toxicological and forensic histological studies have established that hemorrhages might have occurred due to uncontrolled use of diclofenac and warfarin. Conclusion. Subdural hematomas are currently the topical medical and social issue due to the significant growing rate of its incidence. Based on this case, it can be stated that the development of chronic subdural hematoma is caused by the combination of mild trauma and inflammatory response in the damaged dura mater with potentiation of hematoma formation through the use of antithrombotic drugs

Serum Levels of MMP-8 and MMP-9 as Markers in Chronic Subdural Hematoma.

Chronic subdural hematoma (CSDH) is a common neurological disease that involves the collection of blood products in the subdural space. The progression of CSDH is an angiogenic and inflammatory process, but the multifactorial mechanisms underlying CSDH are still not fully understood. We aimed to identify one or more factors that may play an important role in the development of CSDH. We enrolled 83 patients with CSDH, including 17 postoperative patients, and analyzed 20 markers in the hematoma fluid and peripheral blood of each patient. Overall differential gene expression was examined to identify the representative markers. The concentration of MMP-8 was significantly lower in the postoperative group than in the preoperative group. The concentration of MMP-9 was significantly higher in the postoperative group than in the preoperative group. These findings indicate that MMP-8 and MMP-9 may play important roles in the pathophysiology of CSDH. Understanding the pathways associated with CSDH may provide insights for improving disease outcomes.

Factors Favoring the Development of Chronic Subdural Hematoma After Traumatic Acute Subdural Hematoma in the Elderly.

Traumatic acute subdural hematoma (TASDH) is by far the most common traumatic brain injury in elderly patients presented to the emergency department, and a number of those treated conservatively will develop chronic subdural hematoma (CSDH). The factors contributing to chronicity were not well studied in the elderly; therefore, we retrospectively analyzed our elderly patients with acute subdural hematomas to identify the risk factors which might contribute to the development of subsequent CSDH. A retrospective analysis of 254 patients with TASDH admitted between 2012 and 2016 to our level 2 trauma department in a community hospital was collected. Data include age, sex, comorbid conditions, CT findings, anticoagulant therapy, surgical interventions, disposition after discharge, and mortality. Data on those readmitted within the first 2months with the diagnosis of CSDH were also studied (group A), and compared to those not readmitted (group B). Multiple logistic regression was used to determine the risk factors associated with readmission at P ≤ .05. Institutional review board approval was obtained for this study. There were 254 patients who were admitted with TASDH, 144 male (56.7%) and 110 female (43.3%), with the mean age of 71.4 (SD ± 19.38) years. Only 37 patients (14.6%) went for surgery in their initial admission. A total of 14 patients (5.6%) were readmitted subsequently with the diagnosis of CSDH within two months of initial discharge (group A). Only four patients (28.5%) were on anticoagulant therapy and these patients went for emergency craniotomy for evacuation of hematoma. All 14 patients had a history of coronary artery disease and hypertension and only 5 (35.7%) were diabetic. Review of head CT on initial admission of those patients revealed 4 patients (28.5%) had multiple lesions and 4 (28.5%) had tentorial/falax bleeding and 4 (28.5%) had a shift. The initial size and thickness of the bleeding was 1.4-5mm. The adjusted model identified diabetes, race, and initial disposition as significant risk factors (P < .05). Risk associated with the transformation of TASDH to CSDH is difficult to assess in those group of elderly patients because of the small number; however, diabetes, race, and initial disposition to home pointed toward a risk for future development of CSDH and those patients should be followed clinically and radiographically over the next few months after discharge, particularly those on anticoagulant therapy.

Middle Meningeal Artery Embolization for the Treatment of Bilateral Chronic Subdural Hematoma.

Background: Bilateral chronic subdural hematoma (bCSDH) is a frequent condition commonly linked to the need for retreatment; however, the reason for this high retreatment rate remains unclear. The middle meningeal artery (MMA) was found to have a relationship with the occurrence and development of chronic subdural hematomas. This study examines a possible method to reduce bCSDH recurrence using bilateral MMA embolization combined with bilateral burr-hole drainage.Materials and Methods: Ten patients with bCSDH who underwent bilateral MMA embolization combined with bilateral burr-hole drainage at our hospital between June 2018 and May 2020, were retrospectively analyzed. Patients' clinical information, prognoses, imaging results, as well as surgical results were documented and analyzed.Results: Ten patients were diagnosed with bCSDH with no comorbid brain diseases. They underwent bilateral MMA embolization combined with bilateral burr-hole drainage. We embolized the MMA immediately before burr hole drainage successfully and employed angiography to validate these results. All the patients attained relief of symptoms without adverse events, and no re-expansion or relapse was reported in the follow-up computed tomography.Conclusion: Bilateral MMA embolization combined with bilateral burr-hole drainage is an available treatment for patients with bCSDH and may have the potential for preventing recurrence.

Effect of angiotensin converting enzyme inhibitors on the development of chronic subdural haematoma.

Angiotensin converting enzyme inhibitors (ACEI) have been recently discussed in connection with the medical treatment of chronic subdural haematoma (CSDH). They may improve the treatment results. The objective of our study was to evaluate the impact of ACEI on the development of CSDH. The first question was to assess the impact of ACEI on postoperative CSDH healing. The second was to assess the impact of ACEI on the development of CSDH as such. The study recruited patients treated surgically for CSDH at our department in the 2013-2018 period. Based on medical records, we retrospectively evaluated the clinical condition of the patients, their history (mainly pharmacological - the use of ACEI) and the course of treatment focussing on the reoccurrence of disease necessitating further therapeutic interventions. For the purpose of evaluating the impact of ACEI on postoperative CSDH healing, the patients were divided into two groups: those using ACEI and those without this medication. The results were compared. We also compared the prevalence of ACEI use in patients with CSDH with the prevalence of ACEI in the comparable population. The difference of the rates allowed us to evaluate the impact of ACEI on the development of CSDH itself. Of the 217 patients after surgery for CSDH, 79 continued the use of ACEI; the remaining 138 patients did not use this medication. Patients using ACEI after the surgery experienced a recurrence in 24 (30.4%) cases; patients without ACEI in 37 (26.8%) cases. A negligibly higher number of recurrences was recorded in patients with postoperative use of ACEI, but this difference was not statistically significant (P=0.574). Of a total of 230 patients who underwent surgery for CSDH, 81 were using ACEI chronically (35.2%). In the control group of 100 patients, 38 (38.0%) patients used ACEI. The difference was not statistically significant (P=0.629), so it is not possible to assume that ACEIs influence the development of CSDH as such. The initial high hopes for a positive ACEI effect on the healing of CSDH are now waived after the publication of several recent studies. According to our present knowledge, the development of CSDH does not appear to be influenced by ACEI use.

Arachnoid Plasty to Prevent and Reduce Chronic Subdural Hematoma after Clipping Surgery for Unruptured Intracranial Aneurysm : A Meta-Analysis.

ObjectiveRecent studies have reported that arachnoid plasty (ARP) using gelatin sponges with fibrin glue reduced the occurrence of chronic subdural hematoma (CSDH) following clipping surgery for unruptured intracranial aneurysm (UIA). This meta-analysis was conducted to collate further evidence for the efficacy of ARP in preventing postoperative CSDH. MethodsData of patients who underwent clipping surgery were extracted from PubMed, EMBASE, and Cochrane Central Register of Controlled Trials by two independent reviewers. A random effects model was used to investigate the efficacy of ARP by using odd ratios (ORs) and 95% confidence intervals (CIs). A meta-regression analysis for male sex was additionally preformed. ResultsData from six studies with 1715 patients were consecutively included. Meta-analysis revealed that ARP was significantly associated with lower rates of CSDH development after surgical clipping for UIA (ARP group vs. control group : 3.2% vs. 7.2%; OR, 0.40; 95% CI, 0.18–0.93; I2 =44.3%; p=0.110). Meta-regression analysis did not highlight any modifying effect of the male sex on postoperative CSDH development (p=0.951). ConclusionThis meta-analysis indicated that ARP reduced the incidence rates of CSDH following clipping surgery for UIA. If feasible, ARP would be implemented as an additional surgical technique to prevent postoperative CSDH development during surgical clipping of UIA.

Risk factors for the development of chronic subdural hematoma in patients with subdural hygroma

Objective Patients with subdural hygroma (SDG) are at increased risk of developing chronic subdural hematoma (CSDH). However, the factors that increase the risk of conversion are not fully understood. This study was to assess the risk factors of SDG conversion to CSDH. Methods We reviewed the literature and retrospectively studied a series of cases in which CSDH was preceded by SDG to understand the natural history. We reviewed 45 cases of SDG from our hospital between 2015 and 2018. The cases were divided into two groups according to whether SDG converted into CSDH. Data were collected clinical presentation, imaging findings et al. Univariate and multivariate logistic regression analyses were performed to identify factors associated with SDG conversion. Results Univariate analysis showed that the SDG thickness (p = .009), SDG location (p = .026), and bilateral SDG (p = .042) were significantly associated with CSDH development. Multivariate analysis revealed that SDG thickness (odds ratio, 1.6; 95% confidence interval, 1.111–2.324; p = .012) and bilateral SDG (odds ratio, 27.6; 95% confidence interval 2.889–263.548; p = .004) were independent risk factors for SDG development. Receiver operating characteristic curve analysis revealed that SDG thickness was a significant variable for predicting SDG development. A thickness >11.37 mm was an appropriate cutoff value, and the possibility of SDG conversion had a sensitivity 50.0% and specificity of 87.0%. Conclusions Bilateral SDG and SDG thickness were independent risk factors for SDG progression into CSDH. An SDG thickness >11.37 mm had a high risk of SDG conversion.

Extensive postoperative subdural fluid volume affects the onset of chronic subdural hematoma after unruptured aneurysmal clipping surgery

ObjectiveTo evaluate risk factors associated with chronic subdural hematoma (CSDH) onset after clipping surgery for unruptured intracranial aneurysm, and determine whether intraoperative conventional arachnoid-plasty (ARP) can suppress the CSDH onset by reducing subdural fluid volume. Patients and MethodsWe retrospectively evaluated 217 patients who underwent surgical clipping at our institution from 2012 to 2018. Risk and predictive factors for symptomatic CSDH development including clinical characteristics, postoperative subdural fluid volume, Hounsfield unit (HU) value of subdural fluid density evaluated by CT and the effect of conventional ARP were compared between CSDH and non-CSDH groups. ResultsOf 217 patients who underwent surgical clipping for anterior circulation aneurysm, 209 were included in this study. Among whom, postoperative CSDH, required burr irrigation, occurred in 12 (5.7%). Mean age was significantly higher in the CSDH group (70 ± 8 years) than in the non-CSDH group (64 ± 11 years, p = 0.03). Subdural fluid volumes on postoperative day (POD)1, POD8 and POD30 were significantly larger in the CSDH group than in the non-CSDH group (38.4 ± 33.5 cm3, 54.8 ± 36.3 cm3, 77.2 ± 36.1 cm3 vs 10.0 ± 7.7 cm3, 16.1 ± 12.8 cm3, 14.0 ± 17.5 cm3, p < 0.001, respectively). However, intraoperative conventional ARP did not reduce postoperative subdural fluid volume nor suppress onset of CSDH. Multivariate logistic regression analysis revealed extensive subdural fluid volume as the only risk factor independently associated with CSDH development. ConclusionsIn this study, postoperative large subdural fluid volume represented an independent risk factor associated with the incidence of CSDH after unruptured aneurysmal clipping. Reducing subdural fluid volume strategy could suppress the onset of CSDH after surgery.

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.