Management Of cSDH Research Articles

Surgical Management of Chronic Subdural Hematoma in Older Adults: A Systematic Review.

Chronic subdural hematoma (cSDH) is a form of intracranial hemorrhage common in older adults. Optimal treatment remains controversial. We conducted a systematic review to identify surgical thresholds, characterize outcomes, and delineate critical considerations in the surgical management of older adults in order to summarize the evidence supporting the best contemporary management of cSDH. A systematic review exploring surgical management of cSDH among individuals aged 65 years and older was conducting by searching the PubMed, Embase, and Scopus databases for articles in English. Abstracts from articles were read and selected for full-text review according to a priori criteria. Relevant full-text articles were analyzed for bibliographic data, aim, study design, population, interventions, and outcomes. Of 1473 resultant articles, 21 were included. Surgery rationale was case-by-case for symptomatic patients with cSDH. Surgery was superior to conservative management and promoted equivalent neurologic outcomes and rates of complications. Recurrence and reoperation rates in older adults were similar to younger individuals. Some studies reported higher mortality rates for older adults, while others reported no difference. Anticoagulation or antiplatelet agent use did not seem to be associated with poorer outcomes in older adults. Surgery for cSDH in older adults leads to favorable neurologic outcomes without increased risk of overall complications, recurrence, or reoperation compared to younger patients. However, older adults may be at increased risk for mortality after surgery. It is important to determine use of anticoagulant or antiplatelet agents in older adults to optimally manage patients with cSDH.

Practice variation in the conservative and surgical treatment of chronic subdural hematoma

ObjectiveChronic subdural hematoma (CSDH) is a condition that is frequently seen in the neurological and neurosurgical practice. Surgical treatment is overall preferred; however, conservative treatment is also an option. Both surgical and conservative treatment of CSDH vary across neurosurgeons. The aim of the present study was to evaluate different treatment strategies for CSDH among neurosurgeons in different countries. Material and MethodsWe designed a survey that was sent to neurosurgeons affiliated with the Congress of Neurological Surgeons.The questions were related to the conservative and surgical treatment methods of CSDH. Furthermore, we also included questions related to post-operative care. Results443 neurosurgeons completed the survey. 46.2 % of the respondents sometimes use dexamethasone as monotherapy. Overall, 26.2 % estimated dexamethasone to have a high efficacy on CSDH.A Glasgow Coma Score lower than 12 was considered to be the most important indication for surgery by 57.8 %. Double burr hole is the preferred surgical technique by 48.1 % of the respondents. One day after surgery, 69.3 % routinely orders a CT-scan. ConclusionsThe majority of the neurosurgeons worldwide remains reluctant in the use of conservative treatment methods in the management of CSDH. Further research is needed to assess the effectivity and side-effects of these conservative methods.

Middle meningeal artery embolization in the management of chronic subdural haematoma: A case report and review of literature

Chronic subdural hematoma (cSDH) is a common cranial neurosurgical condition with morbidity and mortality ranging from 2% to 5%. Conventional treatment includes conservative and surgical evacuation. Minimally invasive middle meningeal artery (MMA) embolisation is emerging as a potential treatment option. We report our case successfully managed by MMA embolization and review the literature. cSDH development and progression is related to the cycle of chronic inflammation and angiogenesis following the original hemorrhage due to trivial trauma. Due to growth factor, stimulation-initiating angiogenesis leading to growth of leaky blood vessels causing microhaemorrhages resulting in the progressive enlargement of subdural collection as the physiologic absorption capability is outpaced by the rate of collection. Strategies for the management of cSDH are aimed at interrupting the vicious cycle of its development and tilting the balance toward reabsorption of haemorrhage. Conservative management, medical treatment and surgical treatments are conventional treatment options with surgical evacuation considered as the gold standard option. However, challenges include recurrence and reversal of anti-platelets and anti-coagulants and its associated risk of ischaemic complications. cSDH being a pathology of meninges deriving blood the dura causing microhaemorrhages, it is prudent to seal off the vessels to tilt the balance towards resorption. MMA embolisation as a treatment option has been used with significant published data. It may be used as a stand-alone therapy in minimally symptomatic patients. Technical success rate is high both with polyviny alcohol and liquid embolic agents. Recurrence rate is consistently low in spite of significant patients having antiplatelets and anti-coagulants on board. It eliminates the ischemic complication due to stoppage of antiplatelets and anticoagulants. MMA embolization is also emerging as an adjunct to surgically evacuated cSDH that is considered high risk for recurrence.

The Efficacy and Safety of Middle Meningeal Artery Embolization in the Management of Chronic Subdural Hematomas: Systematic Review and Meta-analysis

Abstract INTRODUCTION Refractory chronic subdural hematomas (cSDH) constitute a challenging entity that neurosurgeons face frequently nowadays, especially in fragile elderly populations. Middle meningeal artery embolization (MMAE) has emerged in the past years as a promising treatment option. However, solid evidence is still lacking due to paucity of studies and small sample sizes. METHODS We conducted a systematic review and meta-analysis (MA) in compliance with the PRISMA guidelines to evaluate the efficacy and safety of MMAE compared with conventional treatments for refractory or SDH. Four databases were searched up to March 2019. Using a random-effects model, meta-analyses of proportions and risk difference were conducted on outcomes including recurrence, need for surgical rescue, and complications RESULTS A total of 12 studies (177 patients) were included. Majority (69%) were males with weighted mean age of 71 + −19.5 yr. Rate of chronic alcoholism was 15%, cerebral atrophy 39%, use of anticoagulants/antiplatelets 52%, and history of head trauma 55%. Weighted mean hematoma thickness was 17.9 + −13.3 mm. In embolized patients across 12 studies, proportion MA showed rate of treatment failure to be 2.9% (95% CI = 0.5%-5.2%, I2 = 0%), need for surgical rescue 2.7% (95% CI = 0.4%-5%, I2 = 0%), and embolization-related complications 1.2% (95% CI 0.3%-2.7%, I2 = 0%). Meta-analysis of risk-difference between embolized and nonembolized patients in three double-armed cohort studies showed a 26% lower risk of failure in MMAE (95% CI 21%-31%, I2 = 0, Cochran Q = 0.64) that was statistically significant (P < 0.001). Similarly, in the embolized group, the need for surgical rescue was 20% less (95% CI = 12%-27%, I2 = 12.4, Cochran Q = 2.28) and complications 3.6% less (95% CI 1%-6%, I2 = 0, Cochran Q = 0.31) than in conventional groups, both of which achieved statistical significance CONCLUSION Although MMAE appears to be a promising treatment for refractory or cSDH, drawing definitive conclusions remains limited by paucity of data. Large, prospective trials are needed to compare embolization to conventional treatments, like watchful waiting, medical management, or surgical evacuation. More extensive research of MMAE could begin a new era in the minimally invasive management of cSDH.

Novel use of dual-lumen catheter for irrigation and drainage after evacuation of chronic subdural hematoma

Chronic subdural hematoma (cSDH) is an intracranial pathology most commonly affecting elderly patients. Patients may present with worsening headache, seizures, weakness, balance and gait problems, and memory deficits. Even in patients undergoing hematoma evacuation, there is a substantial risk for recurrence. The authors present the first use of an irrigating external ventricular drain (EVD) in the United States in the perioperative management of a patient with chronic subdural hematoma treated with craniotomy (IRRAS Stockholm Sweden). An 82-year-old male presented with right sided weakness, confusion, and right-sided neglect with expressive aphasia was found to have a large 2.5 cm chronic subdural with 9 mm left to right midline shift. The patient was treated with a mini craniotomy to evacuate the hematoma and placement of an irrigating drain in the subdural space. The patient was discharged home on post-operative day 3 without complication. Patient was at neurological baseline two weeks later upon follow-up. The use of an irrigating drain for perioperative management of cSDH is a novel means to prevent recurrence and warrants further exploration.

A Single Institute Five-Year Surgical Experience with Chronic Subdural Hematoma: Analysis of 270 Consecutive Patients at a Tertiary Care Centre

Abstract Chronic subdural hematoma (CSDH) is one of the very common surgically treatable neurosurgical entities. Still there is lack of uniformity in the management of CSDH amongst surgeons in terms of various treatment strategies and protocols. Burrhole drainage is the treatment modality of choice for an uncomplicated CSDH. Some recent trials support the use of drain to lessen the rate of recurrence. Twist drill craniostomy and craniotomy do also play a role in the management of CSDH. The current study is a retrospective analysis of 270 surgically treated patients with chronic subdural hematoma at a tertiary care center over a span of five years. The present study highlighted on rate of recurrence, re-surgery, mortality and morbidity.

Transcranial color-coded duplex sonography for evaluation of midline-shift after chronic-subdural hematoma evacuation (TEMASE): A prospective study

ObjectiveThe incidence of chronic Subdural hematoma (cSDH) is increasing and its rate of recurrence varies from 5 to 33%. A postoperative brain midline-shift (MLS) on computed tomography (CT) equal or larger than 5mm is a risk factor for recurrence. Transcranial color-coded duplex sonography (TCCDS) is a noninvasive bedside reproducible technique useful to detect MLS. The aim of our study was to compare in patients affected by cSDH, the values of MLS obtained pre- and post-operatively by TCCDS and brain CT. Patients and methods32 patients affected by cSDH entered the study between July 2016 and January 2017. MLS values obtained by TCCDS and brain CT were compared using Bland-Altman plot and linear regression analysis. Using the same techniques we also explored if the agreement between the two imaging modes was comparable in pre- and post-operative data pairs. Results64 data pairs of MLS values obtained by TCCDS and CT were analysed. Bland-Altman diagrams did not show any systematic bias of the data and linear regression indicated a significant correlation between the two measures both before and after hematoma evacuation. ConclusionIn patients affected by cSDH, MLS values obtained before and after surgery by TCCDS are comparable to those obtained by CT; TCCDS might be considered an alternative to CT scan in the management of patients after cSDH evacuation. We suggest that close clinical bedside examination and TCCDS might be appropriate for the post-operative management of cSDH, reserving CT scan only to patients with overt clinical deterioration and/or increasing MLS.

Burr-Hole Craniostomy for Chronic Subdural Hematomas by General Surgeons in Rural Kenya.

Chronic subdural hematoma (cSDH) is a common condition that causes significant morbidity and mortality. In rural sub-Saharan Africa, there are very few neurosurgeons. Yet, cSDH is treatable by relatively simple surgical intervention with potential for rapid clinical improvement. We conducted a retrospective chart review of all patients with cSDH who underwent burr-hole trephination at Tenwek Hospital, Kenya, between July 2014 and July 2016. We extracted and compared the clinical presentation, risk factors, operative details, and outcomes. A total of 119 patients were identified with a mean age of 61.3years. The majority were men (80%). The main predisposing factors were trauma (54.6%) and alcohol intake (34.4%). Patients were generally managed with two burr-holes, irrigation, and a subdural drain, remaining for a median of 2days. Operations were assisted by general surgery residents under direct supervision of senior residents (46), general surgeons (65), and neurosurgeons (8). Complications included recurrence (5.2%), subdural empyema (2.5%), postoperative seizures (3.4%), and mortality (6.7%). Improvement of symptoms was noted in 91% of all patients. Operative management of cSDH can be safely performed in rural facilities by general surgeons familiar with the procedure and with the institutional resources. The majority of patients had satisfactory outcomes.

The Subdural Evacuation Port System: Outcomes from a single institution experience and predictors of success

IntroductionNumerous surgical options for treatment of chronic subdural hematomas (cSDH) exist. Several reports have examined the Subdural Evacuating Port System (SEPS), a variation of the twist drill craniotomy (TDC) technique. Although high success rates have been reported, a significant portion of patients treated with SEPS fail and require additional procedures. This report examines the largest single institution experience with the SEPS and explores patient and imaging characteristics associated with successful procedures. MethodsA retrospective chart review was performed to identify all patients who have undergone SEPS drainage of cSDH. Demographic and radiographic characteristics were evaluated. Demographic data included patient's age, sex, presenting symptoms, pre-procedural GCS score, and use of anticoagulation or antiplatelet agents. The volume of drainage per procedure and radiographic data including laterality, density, and maximal diameter of the collection, presence of septations, midline shift, resolution of the collection 3 weeks post procedure, and measurements to assess atrophy were collected. Total length of stay and time in the intensive care unit was also recorded. Results were classified as a success or failure based on the need for additional procedures including craniotomy or burr hole craniotomy in the operating room. Patients treated with two SEPS procedures during the same hospitalization and no other procedures were included in the success group for statistical analyses. Results171 subdural collections were treated in 159 patients (147 unilateral and 12 bilateral). One hundred thirty three collections (77.8%) were successfully drained. In a comparison of the success and failure groups, there were no statistically significant differences (p<0.05) in the patients’ mean age, sex, presenting Glasgow Coma Scale score, coagulation profile, presenting symptoms (except altered mental status and language disturbance), subdural diameter or laterality, midline shift, presence of atrophy, density of most acute portion, or time in hospital. In the success group, there was a shorter mean stay in the intensive care unit (S: 4.1±4.5 days vs F: 5.4±4.6 days; p=0.03) and a larger output drained (S: 131.1±71.2ml vs F: 99.0±84.2ml; p=0.04). Success was less likely with mixed density collections (S: 38.2% vs F: 64.3%; p=0.02) and with collections containing greater than 2 intrahematomal septations (S: 17.1% vs F: 40.7%; p=0.007). In successful cases, mean volumes for collections prior to SEPS, immediately after SEPS, and on delayed scans (≥30 days since SEPS placement) the respective volumes were 83.1±35.1ml, 41.5±23.2ml, and 37.9±26.5ml. Both post-SEPS volumes were less than the pre-SEPS volume (p<0.0001). 76.0% of patients with delayed scans had complete resolution of cSDH or minimal residual cSDH with no local mass effect on the most recent imaging. The mean period of follow-up imaging was 95.6±196.2 days. Only one patient in our series required an emergent craniotomy following immediate complications from SEPS placement. ConclusionsThe SEPS is an effective, safe, and durable treatment for cSDH. Although we consider the SEPS a first-line treatment for the majority of patients with cSDH, management of cSDH must be tailored to each patient. In mixed density collections with large proportions of acute hemorrhage and in collections with numerous intrahematomal septations, alternative surgical techniques should be considered as first-line therapies.