Incidence Of Chronic Subdural Hematoma Research Articles

Endovascular treatment of subdural haematoma in patient under anti-platelet therapy: a case report

Introduction: The incidence of chronic subdural haematoma (cSDH) is relatively high among the elderly population. Other known risk factors for cSDH include male sex, dependency on anti-platelet or anticoagulant medication, and chronic alcoholism. Although, the standard mode of treatment for cSDH is surgery, embolization of the middle meningeal artery (MMA), either upfront or as an adjunct to surgical evacuation can be used for the treatment of cSDH. Case presentation: The authors present a case of a 75-year-old female with prior history of posterior-lateral wall myocardial infarction (MI) eight years back presented to our centre with the chief complaints of a gradual onset of cough and headache for 2 months. The patient had no history of trauma, loss of consciousness, seizures, and vomiting. There was no history of diabetes, hypertension, pulmonary tuberculosis, and other chronic illness. Discussion: The concurrent use of anti- platelet drug during a surgical procedure can make the treatment challenging. Endovascular treatment can be a primary treatment modality in such situation. Conclusion: Elimination of blood supply by middle meningeal artery embolization is emerging as a safe, minimally invasive alternative to treat cSDH.

Incidence of Chronic Subdural Hematoma after Mild Head Trauma in Elderly Patients with or without Pre-traumatic Conditioning of Anti-thrombotic Drugs.

Anti-thrombotic drugs may increase the risk for chronic subdural hematoma (CSDH). However, whether to continue or discontinue/counteract these drugs has not been investigated in patients with mild head trauma. CSDH incidence after mild head trauma, as well as the risk for CSDH in patients with anti-thrombotic drugs, were investigated in this study. The study included 765 consecutive elderly (>65 y.o.) patients with mild head trauma and an initial Glasgow Coma Scale (GCS) score of 14 or 15. All patients received initial CT within 24 hours after trauma and were re-examined 30 days after trauma to detect CSDH formation, repeating for every 30 days to examine symptomatic CSDH progression. Patients were divided into two groups, with anti-thrombotic drugs (n = 195) or without them (n = 263), to investigate the influence of pre-traumatic conditioning with anti-thrombotic drugs on CSDH. The whole sample was 458 out of 765 cases. The incidence of CSDH formation was 91 out of 458 cases (19.9%) after mild head trauma, with no significant difference between with and without anti-thrombotic drugs. CSDH progressed as symptomatic in 21 out of 458 cases (4.6%), with no significant difference between with and without anti-thrombotic drugs. Pre-traumatic conditioning with anti-thrombotic drugs and its continuation after trauma did not affect the incidence of formation or symptomatic progression of CSDH. This finding suggests that discontinuing and/or counteracting anti-thrombotic drugs may be unnecessary in patients with mild head trauma.

Validating the Efficacy of Two Burr-Hole Craniostomy over Mini-Craniotomy for Chronic Subdural Hematoma Drainage.

Background There is an increasing incidence of chronic subdural hematoma due to extended life expectancy and associated trauma and fall risk. This retrospective study evaluates the efficacy of two burr-hole craniotomy over mini-craniotomy. Methods Sixty-five patients were recruited over 2 years, of which 56 were male and 9 were females. A patient with a chronic subdural hematoma either underwent burr-hole craniostomy or mini-craniotomy for hematoma evacuation. Glasgow coma scale (GCS) and modified Rankin score were used to assess the neurological status and interventional outcome at discharge and follow-up, respectively. A head CT scan was performed at 3 week and 3 month follow-up. Statistical Analysis Categorical data are presented as frequency and percentage, while non-categorical data are represented as mean ± SD. Statistical significance for difference in outcome between the two groups was analyzed using the chi-square test and p -value less than 0.05 was considered statistically significant. Results The mean age of patients was 55.6 years. Headache (35 cases), hemiparesis, and altered sensorium were seen in 20 patients, each with the main presenting symptoms. Trauma history was noted in 69.2% of patients. One (3.7%) hematoma recurrence in the burr-hole group and four (8.3%) in the mini-craniotomy group was recorded. The mean operative time was longer in the minicraniotomy group (124.2 min vs. 75.4 min; p < 0.001). A higher incidence of recurrence was noted in the craniotomy group (8.3%) than the burr-hole group (3.7%). No statistical difference in the recurrence rate, duration of hospital stay, GCS at discharge, modified Rankin score between the two study groups at discharge was noted. Conclusion Two burr-hole craniostomy is a safe and effective surgical option to treat chronic subdural hematoma. It is also validated in patients on anticoagulants and antiplatelet medications with adequate pre-surgical correction of coagulation parameters.

Embolization of the Middle Meningeal Artery for the Treatment of Chronic Subdural Hematoma: A Path Less Travelled So Far.

Introduction Chronic subdural hematoma (CSDH) is relatively common and usually encountered in elderly population. With steady increase in life expectancy, incidence of CSDH also is bound to increase proportionately. Though surgery is the treatment of choice and relatively a simpler procedure, recurrence is a cause of concern. Embolization of the middle meningeal artery (MMA) is a newly evolving treatment modality in CSDH and offers hope in some of the recently published case series. Materials and Methods Five cases of CSDH were subjected to embolization of MMA over a period from October 2019 to July 2020. Among them, it was employed for treatment in four cases after at least two recurrences following surgery, and in one case, it was done as the patient was not fit for surgery. All procedures were done under general anesthesia and polyvinyl alcohol (PVA) particles were used for embolization. Follow-up of the patients were done with computed tomography brain at 4 weeks and after 6 months of the procedure. Results There was no incidence of recurrence in our series. Furthermore, embolization per se did not cause any complication or side effect which could be directly attributable to the procedure itself. Conclusion In carefully selected patients based on clinical profile and angiographic findings, MMA embolization can be an effective modality for the treatment in CSDH.

Decline in the Incidence of Chronic Subdural Hematoma During the Coronavirus Disease 2019 Pandemic: A Retrospective Single-Center Descriptive Study.

The coronavirus disease 2019 (COVID-19) pandemic has forced restrictions on social activities in some areas. There has also been a decrease in the number of trauma patients in the United States during the COVID-19 pandemic. Chronic subdural hematoma (CSDH) is a traumatic disorder that often develops following head injury. We therefore investigated the impact of the COVID-19 pandemic on CSDH. In this retrospective single-center descriptive study from April 2018 through September 2021, there were 5,282 head trauma patients and 196 patients with CSDH in the pre-pandemic group compared to 4,459 head trauma patients and 140 patients with CSDH in the intra-pandemic group. Significant decreases in the incidence rate (IR) of head trauma (951/100,000 vs. 795/100,000 person-years; IR ratio (IRR): 0.836, 95% confidence interval (CI): 0.803–0.870, p < 0.001) and also in the IR of CSDH (35.0/100,000 vs. 24.8/100,000 person-years, IRR: 0.708, 95% CI: 0.570–0.879, p = 0.002) were seen in the intra-pandemic group compared to the pre-pandemic group. In this study, the COVID-19 pandemic was associated with significant decreases in the IRs of head trauma and CSDH due to forced restrictions on social activities. Besides, the IR of mild cases of CSDH was significantly lower in the intra-pandemic group than in the pre-pandemic group (IRR: 0.68, 95% CI: 0.51–0.89, p = 0.006). Fewer people being out in communities should result in fewer chances for head trauma and CSDH. On the other hand, forced restrictions on social activities due to the COVID-19 pandemic should aggravate CSDH.

Chronic subdural haematoma- A dilemma of most common aetiological factor

Background: Chronic subdural haematoma (CSDH) is common of all intracranial haemorrhages specially in old age. Mortality is still 13% after invention of simplest and latest technique including operation. Incidence of CSDHs in over 65 years is 58.1 per 100,000 per year but only 3.4 per 100,000 per year in those under 65 years of age. So, age has a great role inducing CSDH, there is also chance of intracranial haemorrhage on anti-platelet &amp; anticoagulant drugs, platelet &amp; coagulation dysfunction. Major trauma to head produces acute haematoma but minor trauma should take into cognizance for CSDH. The purpose of this study was to take details history, analysis of patients to find out aetiological factors of chronic subdural haematoma and to take precautions regarding them specially most one to avoid preventable morbidity and mortality. Materials and Method: This prospective study was carried out in Combined Military Hospital (CMH), Dhaka from March 2018 to March 2019. All of our patients above 20 years of age; were admitted and diagnosed clinically and confirmed by CT scan head as CSDHs. Total number of patients were 50; randomly allocated and sampling was done as per inclusion and exclusion criteria. Elaboration of details history, through examination including neurological examination, meticulous investigations including CT scan of head was done. Statistical analyses were performed by using the Statistical Package for Social Sciences version 26 for Windows (SPSS). Results: In our study 50 cases were finally selected as CSDHs and diagnosed clinically then confirmed radiologically. The most of the patients 39 (78%), 51-80 years age group, male were 41(82%) and female were 9(18%) in number. In this study, it was observed that unknown aetiology 7(14%), on anti-platelet drug 10(20%), on anti-coagulant drug 6(12%) and 27(54%) subjects had trivial head trauma. Explored aetiology; trivial head trauma, on anti-coagulant and anti-platelet medication were 43(86%) in number. Conclusion: Diagnosis of CSDH is relatively easier than to find out aetilogy. We should cautious about the causative factors specially most common like trivial head trauma in old age &amp; keen observe them and avoid coagulopathic medication if not essential.

Retrospective analysis of 195 surgically treated cases of chronic subdural hematoma.

The incidence of chronic subdural hematoma (CSDH) is increasing. This study evaluates the etiologic causes and findings of CSDH and compared unilateral CSDH with bilateral CSDH. This study aims to draw attention to this increasingly prevalent condition. We retrospectively analysed 195 surgically treated cases of CSDH in our clinic between 2008 and 2018. The average age of the patients was 65.7 ± 19.6 years. The most common symptom was headache (53.3%). The case background was the use of anticoagulant (37.9%), head trauma (34.3%). The hematomas were 28.7% right side, 44.6% left side, and 26.7% bilateral. The mean Glasgow Coma Score (GCS) was 13.4 ± 2.9, early postop 13.8 ± 2.5, and late postop was 14.6 ± 1.1. Postoperative complications included acute subdural hematoma (5.1%), cerebral infarction (1.5%), wound infection (0.5%) and others (13.3%). Re-expansion of the brain were statistically significantly less frequent and impaired consciousness, anticoagulant use, early and late postop thickness were statistically significantly more frequent in patients with bilateral CSDH. CSDH is seen more patients of advanced age, those who use anticoagulants, patients with hypertension and diabetes and in patients with a history of head trauma. Prognosis is worse in bilateral CSDH. We estimate that the incidence of CSDH will go up in the future.

Postoperative recurrence of chronic subdural hematoma is more frequent in patients with blood type A.

Because of an aging society, the incidence of chronic subdural hematoma (CSDH) is increasing. This lesion is treated with simple burr hole irrigation, but one of the major issues is that CSDH frequently recurs. ABO blood type may be associated with a bleeding tendency and inflammation. However, its association with the recurrence of CSDH remains unknown. Therefore, the authors of the present study aimed to retrospectively investigate the association between ABO blood type and CSDH recurrence. The authors retrospectively analyzed symptomatic CSDHs in 425 cerebral hemispheres of 376 patients who had undergone surgical treatment with irrigation of the hematoma via burr holes at their institution from January 2011 to September 2019. Among these were 366 CSDHs in 320 patients whose ABO blood type had been determined and who were included in this study. In the study, 307 patients with CSDHs in 350 hemispheres were followed up postoperatively until the disappearance of the CDSH or for at least 3 months. Recurrence of CSDH was observed in 37 patients (10.6%) after surgical treatment. Blood type A was found to be significantly associated with CSDH recurrence compared to non-A blood types: 24 of 153 CDSHs (15.7%) versus 13 of 197 CDSHs (6.6%) (p = 0.008). In the multivariable regression analysis, blood type A, in addition to thrombocytopenia, was a significant independent predictor of the recurrence of CSDH. The study results showed that blood type A is an independent risk factor for the postoperative recurrence of CSDH and that careful follow-up in these patients may be needed.

Relevance of comorbidities and antithrombotic medication as risk factors for reoperation in patients with chronic subdural hematoma

In an aging Western society, the incidence of chronic subdural hematomas (cSDH) is continuously increasing. In this study, we reviewed our clinical management of cSDH patients and identified predictive factors for the need of reoperation due to residual or recurrent hematomas with a focus on the use of antithrombotic drugs. In total, 623 patients who were treated for cSDH with surgical evacuation between 2006 and 2016 at our department were retrospectively analyzed. Clinical and radiological characteristics and laboratory parameters were investigated as possible predictors of reoperation with univariate and multivariate analyses. Additionally, clinical outcome measures were compared between patients on anticoagulants, on antiplatelets, and without antithrombotic medication. In univariate analyses, patients on anticoagulants and antiplatelets presented significantly more often with comorbidities, were significantly older, and their risk for perioperative complications was significantly increased. Nevertheless, their clinical outcome was comparable to that of patients without antithrombotics. In multivariate analysis, only the presence of comorbidities, but not antithrombotics, was an independent predictor for the need for reoperations. Patients on antithrombotics do not seem to necessarily have a significantly increased risk for residual hematomas or rebleeding requiring reoperation after cSDH evacuation. More precisely, the presence of predisposing comorbidities might be a key independent risk factor for reoperation. Importantly, the clinical outcomes after surgical evacuation of cSDH are comparable between patients on anticoagulants, antiplatelets, and without antithrombotics.

Incidence of chronic subdural haematoma: a single-centre exploration of the effects of an ageing population with a review of the literature

BackgroundChronic subdural haematoma (cSDH) is a common neurosurgical pathology frequently occurring in older patients. The impact of population ageing on cSDH caseload has not been examined, despite relevance for health system planning.MethodsThis is a single-centre study from the UK. Operated cases of cSDH (n = 446) for 2015–2018 were identified. Crude and directly standardised incidence rates were calculated. Medline and EMBASE were systematically searched to identify studies reporting on the incidence of cSDH by year, so an estimate of rate of incidence change could be determined. Local incidence rates were then applied to population projections for local catchment area to estimate operated cSDH numbers at 5 yearly intervals due to shifting demographics.ResultsWe identified nine studies presenting incidence estimates. Crude estimates for operative cases ranged from 1.3/100,000/year (1.4–2.2) to 5.3/100,000/year (4.3–6.6). When non-operated cases were included, incidence was higher: 8.2/100,000/year (6.0–11.2) to 48/100,000/year (37.7–61.1). Four pairs of studies demonstrated incidence rate increases of 200–600% over the last 50 years, but data was deemed too heterogeneous to generate formal estimate of incidence change. Local crude incidence of operated cSDH was 3.50/100,000/year (3.19–3.85). Directly standardised incidence was 1.58/100,000/year (1.26–1.90). After applying local incidence rates to population projections, case numbers were predicted to increase by 53% over the next 20 years.ConclusionsThe incidence of cSDH is increasing. We project a 53% increase in operative caseload within our region by 2040. These are important findings for guiding future healthcare planning.

Potentially inappropriate medication usage, fall and comorbidities in geriatric patients diagnosed with chronic subdural hematoma

Aim: The annual incidence of chronic subdural hematoma is 2-4/100000 in geriatric population. We aimed to investigate relationship between potentially inappropriate medication usage according to Beers 2019 criteria, fall and Charlson comorbidity index in geriatric patients diagnosed with chronic subdural hematoma.&#x0D; Materials and Methods: We retrospectively collected medical records of 69 geriatric patients diagnosed with chronic subdural hematoma and hospitalized for the last 5 years in neurosurgery department of Izmir Katip Çelebi University Hospital with the permission of local ethical committee of medical faculty. Data was recorded and analyzed with appropriate method by using SPSS v18.&#x0D; Results: Mean age was 78.43 ± 7.51 years, mean Charlson comorbidity index was 5.87 ± 2.97. Falling events were responsible for 59 (85.5%) out of 69 chronic subdural hematoma cases. Potentially inappropriate medication usage according to Beers 2019 criteria was found in 20 (29%) patients. Inappropriate medications belonged to cardiovascular system (14.5%) class and antiplatelet/anticoagulant (14.5%) class mostly. When group was divided into two groups as patients who used potentially inappropriate medication or not, Charlson comorbidity index was found to be higher in the first group. (p 0.05). Charlson comorbidity index and number of medications showed significant correlation (p = 0.001).&#x0D; Conclusion: We could not reach a significant correlation between fall, Charlson comorbidity index and potentially inappropriate medication usage in our retrospective study. Small study population size, unreliable medical records and relatively healthy characteristics of population may contribute to crossing results.

Incidence of chronic subdural haematoma in different age groups and its surgical management

Background: Chronic SDH is a condition which usually affects the elderly population. Trauma is the most common cause of chronic subdural haematoma. Surgical Treatment of chronic subdural haematoma includes burr holes with or without drainage. In patients with membrane formation, craniotomy is considered. Aims: To know the incidence of chronic subdural haematoma in different age groups, the risk factors for its occurrence and its surgical management. Settings and Design: The incidence of chronic SDH in different age groups and the different surgical procedures done for its management were noted. Materials and Methods: Fifty patients of chronic SDH who underwent surgical intervention were analysed. Statistical analysis: Statistical evaluation was done Results: Mean age was 62.06 years. 54% of patients were in the age group of >62 years. Mostly (56%) chronic subdural haematoma was on the right side. Right side chronic subdural haematoma patients had mean age of 60.8 years, left side chronic subdural haematoma patients had mean age of 56.7 years and bilateral chronic subdural haematoma patients had mean age of 75.6 years. Trauma (46%) was most commonly associated with chronic SDH formation. Burr hole evacuation was the preferred surgical treatment modality (92%). Conclusion: Chronic SDH usually occurs in elderly population. Bilateral Chronic SDH is commonly seen in elderly patients. Traumatic brain injury is the commonest predisposing factor for its occurrence. In some elderly patients even a trivial injury may lead to the occurrence of chronic SDH. Keywords: Chronic subdural haematoma, Burr hole drainage, Age related incidence, Bilateral chronic SDH.

Worse Outcomes with Dexamethasone for Symptomatic Chronic Subdural Hematoma

The incidence of chronic subdural hematoma has been increasing as the population ages and the use of antithrombotic therapy widens. Surgical evacuation

Clinical triad of chronic subdural haematoma

Background: Chronic subdural haematoma (CSDH) is one of the common intracranial haemorrhages mostly affecting the elderly population. It has a great role in morbidity and mortality, yet it is treatable by relatively simple technique and the majority of patients improve rapidly following surgical intervention but mortality rate is still 13%. The incidence of CSDHs in over 65 years is 58.1 per 100,000 per year compared to 3.4 per 100,000 per year in those under 65 years of age. Most of the population in developing country like Bangladesh resides in rural area; and there is less opportunity to do Computed Tomography (CT) scan brain. So better to diagnose clinically and then confirmed by CT scan to provide necessary treatment timely to reduce suffering of the patient.The purpose of this present study was to take details history, analysis symptoms and meticulous examination to diagnose CSDHs clinically, so that further CT scan of very diagnostic cases could be done to treat properly. Materials and Method: This study was conducted in the Department of Combined Military Hospital (CMH), Dhaka from March 2018 to February 2019 and it is a prospective study. The patients more than 20 years who were admitted and diagnosed clinically and all confirmed as CSDH by non-contrast CT scan head. A total 50 patients randomly allocated and sampling was done as per inclusion and exclusion criteria but must exclude who were not CT scan positive findings. Details history, meticulous symptom imprinting, keen physical examination including neurological examination and finally data collection with CT scan-head was done. Statistical analyses were carried out by using the Statistical Package for Social Sciences version 26 for Windows (SPSS). Results: In this study 50 cases were finally selected as &lsquo;Chronic Subdural Haematoma&rsquo; and all were diagnosed clinically and radiologically confirmed. It was observed that most of the patients 39 (78%), 51-80 years age group. Regarding distribution of gender male were 41 &amp; female were 9 in number. In our study subjects, it was noticed that 43(86%) subjects had trivial head trauma, on anti-platelet and anti-coagulant medication. Regarding clinical picture of these CSDHs, it was observed that less number of patients only 5 (10%) patients had hemiparesis &amp; vomiting but 45(90%) subjects had Headache, Dysphasia and Altered level of consciousness. Conclusion: Diagnosis of CSDH by details history and meticulous clinical tests is easily accessible, less costly and effective in dubious mass population. Much suspected cases by clinical means can be confirmed by CT scan head and at least on time treatment could reduce morbidity as well as mortality of developing to poor country.

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

Anticonvulsants for Preventing Seizures in Patients with Chronic Subdural Haematoma: Pilot Study

Introduction: There is increasing of the incidence of chronic subdural hematomas (CSDH), due to increase of the elderly population with increase of intake oral anticoagulation and antiplatelet drugs in this category of patients. Seizures occur as a complication in 2.3% to 20.4% of the patients. There is a considerable side effect associated with using of anti-epileptic drugs (AEDs). Aim of the Study: To rule the value of prophylactic antiepileptic drugs in prevention of seizures after surgical evacuation of chronic subdural hematoma. Methods: A prospective controlled non-randomized study was performed on 26 patients with chronic or subacute subdural hematoma that was surgically evacuated through burr-holes from April 2017 to June 2019. We divided the patients into 2 groups: group A patients received prophylactic antiepileptic drugs for 6 month and group B patients didn’t receive prophylactic antiepileptic drugs and the 2 groups were observed to detect occurrence of post-operative seizures for 6-month follow-up after surgery. Medical history, demographic data and imaging characteristics were recorded. Results: Seizure prevalence for all patients during hospitalization and 6-month follow-up was zero among the 13 patients who received prophylactic anti-seizure medications, and was 1 (7.7%) among the 13 patients who didn’t receive prophylactic anti-seizure medications. Conclusions: The incidence of post-operative seizures in patients with chronic subdural hematoma operated upon by burr holes evacuation is low. The administration of prophylactic antiepileptic drugs decreases the incidence of seizures after evacuation of CSDH, but the difference was not significant. So prophylactic antiepileptic drugs should not be routinely given for all patients with CSDH operated upon by burr hole evacuation unless there is risk factor for seizure development.

Influence of Meteorological Conditions on the Incidence of Chronic Subdural Haematoma, Subarachnoid and Intracerebral Haemorrhages - the "Bleeding Weather Hypothesis".

To elucidate possible causal relationships on climate change and intracranial haematomas. In a retrospective study we examined all patients (N=1169) treated for subarachnoid haemorrhage (SAH; n=484), intracerebral haemorrhage (ICH; n=417) or chronic subdural haematoma (CSDH; n=268) in our department over a 7-yearperiod between 1st June 2005 until 31th May 2012. The date of admission was correlated with the corresponding meteorological parameters which included; mean daily temperature (°C), relative humidity (%), vapor pressure (hPa), barometric pressure (hPa), cloud amount (/8), and wind speed (m/s). Incidence of SAH tended to increase in April, ICH in January and CSDH in July, respectively, but ?² test did not reveal any statistical significance in seasonality for the three bleeding pathologies. Comparing the arithmetic average of meteorological key parameters of uneventful and eventful days by using student?s t-test within the three groups (SAH, ICH, CSDH) we could not demonstrate any statistical significance (p > 0.05). For SAH, logistic regression analyses revealed an increased risk associated with a decrease of barometric pressure (p=0.021). Although our data suggest seasonal variabilities of SAH, ICH and CSDH, the single weather parameters do not demonstrate causal relationships with the incidence of cerebrovascular events. However, incidence of SAH tended to increase with changes of barometric pressure which confirms previously published results and might indicate a possible underlying relationship.

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.

Intraoperative Mannitol Administration Increases the Risk of Postoperative Chronic Subdural Hemorrhage After Unruptured Aneurysm Surgery

Although mannitol is used widely to facilitate brain retraction in cases of ruptured aneurysms, there is no consensus about the intraoperative administration of mannitol in the case of unruptured aneurysms. Accordingly, this study was conducted to identify an intraoperative mannitol administration strategy. Mannitol was administered routinely to patients (n= 90) from January 2015 to April 2016 and not administered to patients (n= 97) from May 2016 to June 2017. The patient groups with and without mannitol administration were then compared based on the patient medical records, radiologic data, and digital recordings from an intraoperative microscope. The patient groups with and without mannitol administration were comparable regarding patient age, number of elderly patients, sex, and aneurysm locations. No between-group difference was identified in terms of the intradural procedural time, retraction-induced cortical injury, postoperative electrolyte imbalance, symptomatic infarction, and postoperative epidural hematomas. However, the patient group without mannitol administration showed a significantly lower incidence of chronic subdural hematomas (CSDHs) >50 mL (13.3% vs. 3.1%, P= 0.010). Moreover, a multivariate analysis revealed that an advanced age (P= 0.019), male sex (P <0.001), and mannitol administration (P= 0.040) were all statistically significant risk factors for a postoperative CSDH >50 mL following unruptured aneurysm surgery. Withholding the administration of mannitol during a pterional or modified procedure for unruptured aneurysms was found to reduce the postoperative occurrence of a CSDH without increasing the operative difficulties or other postoperative complications.

The Danish chronic subdural hematoma study-predicting recurrence of chronic subdural hematoma.

Anincreasing incidence of chronic subdural hematoma (CSDH) and an unchanging high recurrence rate of 10-20% call for individualized treatment. The aim of this study was to establish individualized prediction models for the risk of recurrence treating death as a competing risk. A retrospective national cohort of unilateral CSDH was included for analysis. Using competing risk survival analysis, we tested whether available covariates were associated with the risk of recurrence. We further established a pre- and a postoperative prediction model, where predictors were chosen using a LASSO approach. The models were visualized in nomograms. Predictive performance was evaluated by c index and calibrations plots. A total of 763 patients with surgically evacuated unilateral CSDH were included for analysis. The recurrence rate was 14% while 12% of patients died during follow-up (1year). In our association model, hematoma size, drain type, drainage time, presence of complications, and Glasgow Coma Score were significantly associated to recurrence. Subdural drain was associated with a lower recurrence risk than subgaleal drain. The preoperative model included hematoma size, hematoma density, and history of hypertension. The postoperative model included further drain type, drainage time, and surgical complications. The nomograms allow easy assessment of the recurrence risk for the individual patient, providing a better possibility for individual adjustment of treatment and follow-up. The predictive performance indicates that significant unaccounted or unknown factors still remain. The association test found passive subdural drain superior to passive subgaleal drain in minimizing the risk of CSDH recurrence.