Recurrence Of Subdural Hematoma Research Articles

Comparison of Two Drainage Systems on Chronic Subdural Hematoma Recurrence.

Chronic subdural hematoma (CSDH) is a common type of intracranial hemorrhage, especially among the elderly, with a recurrence rate as high as 33%. Little is known about the best type of drainage system and its relationship with recurrence. In this study, we compare the use of two drainage systems on the recurrence rate of CSDH. We retrospectively analyzed the charts of 172 CSDH patients treated with bedside twist drill craniostomy (TDC) and subdural drain insertion. Patients were divided into two groups: group A (n = 123) received a pediatric size nasogastric tube [NGT]), whereas group B (n = 49) had a drain commonly used for external ventricular drainage (EVD). Various demographic and radiologic data were collected. Our main outcome was recurrence, defined as symptomatic re-accumulation of hematoma on the previously operated side within 3 months. In all, 212 cases of CSDH were treated in 172 patients. The majority of patients were male (78%) and had a history of previous head trauma (73%). Seventeen cases had recurrence, 11 in group A and 6 in group B. The use of antiplatelet and anticoagulation agents was associated with recurrence (p = 0.038 and 0.05, respectively). There was no difference between both groups in terms of recurrence (odds ratio [OR] = 1.42; 95% confidence interval [CI]: 0.49-4.08; p = 0.573). CSDH is a common disease with a high rate of recurrence. Although using a drain postoperatively has shown to reduce the incidence of recurrence, little is known about the best type of drain to use. Our analysis showed no difference in the recurrence rate between using the pediatric size NGT and the EVD catheter post-TDC.

Y Stenting in Wide-Necked Bifurcation Aneurysms: A Single-Center Experience

AbstractStent-assisted coiling is an endovascular means of managing wide-necked bifurcation aneurysms. In spite of the wide availability of various newer devices in managing such difficult aneurysms, the Y stenting offers a safe and cost-effective alternative to treat such cases in resource poor settings. This article provides an insight of our initial six cases of Y stent-assisted coiling along with their follow-up over a period of 6 months with no recanalization in any case. It also highlights the various technical aspects involved in such cases. One case had recurrent subdural hematoma probably due to use of antiplatelets and another patient had sudden dip in level of consciousness probably due to hematoma expansion that might also have been due to antiplatelet usage. However, none of the cases had any issues regarding stent migration, malapposition, and dissection. In our experience, Neuroform Atlas stent used for Y stenting offers a safe and technically easy alternative to various newer bifurcation devices.

Identification of Radiological and Clinical Factors that Increase the Risk of Chronic Subdural Hematoma Recurrence.

To determine risk factors predicting chronic subdural hematoma (CSH) recurrence is a common type of intracranial hemorrhage in elderly patients. Despite improved medical diagnosis and treatment, the reoperation rate remains high. A retrospective review of 291 CSH patients admitted to our department was performed. Clinical and radiological factors predictive for CSH recurrence were identified by univariate analyses; variables whose p-value was < 0.05 underwent multivariate logistic regression analyses. Univariate analyses revealed that preoperative midline shift (p=0.025), mix-density hematoma (p=0.023), internal architecture of hematoma (p=0.044), membranectomy (p=0.001), and ambient cistern compression (p=0.001) correlated with a significantly higher rate of recurrence. Multivariate analyses showed that separated architecture, membranectomy and ambient cistern compression were independent risk factors for CSH recurrence. Among many factors, membranectomy, separated architecture, and ambient cistern compression were the strongest predictors for recurrence.

Chronic subdural hematoma recurrence due to contralateral neovascularization following middle meningeal artery embolization.

Chronic subdural hematoma (CSDH) is one of the most commonly encountered neurosurgical diseases. Middle meningeal artery embolization (MMAE) is a technique for the management of CSDH that has elicited promising results. Despite the encouraging results of MMAE, recurrence does occur. One uncommon mechanism for recurrence of CSDH is by means of neovascularization of the contralateral middle meningeal artery (MMA). We describe two cases of CSDH recurrence by means of contralateral middle meningeal artery neovascularization treated with contralateral MMAE. We identified two cases of recurrent subdural hematoma secondary to neovascularization following treatment with contralateral MMAE. Two patients initially treated with MMAE were identified with CSDH recurrence secondary to contralateral MMA neovascularization. There was no traumatic or coagulopathic contribution to CSDH recurrence. In both cases, patients underwent contralateral MMAE. Both patients were neurologically intact with radiographic improvement of CSDH at follow up. Re-accumulation of SDH following MMAE by means of contralateral MMA neovascularization is a rare subtype of subdural hematoma (SDH) recurrence following MMAE. Within the context of re-accumulation of SDH following MMAE, catheter angiography is an important diagnostic investigation to elucidate the etiology of the recurrence. Furthermore, when angiography reveals neovascularization of the contralateral MMA, embolization of the contralateral MMA achieves good clinical and radiographic result.

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.

Use of the Subdural Hematoma in the Elderly (SHE) Score to Predict 30-Day Mortality After Chronic Subdural Hematoma Evacuation

The Subdural Hematoma in the Elderly (SHE) score has been recently developed to assess the 30-day mortality in acute and chronic subdural hematomas in patients >65 years and has shown good reliability. We aimed to validate the SHE score's accuracy to predict 30-day mortality on a homogeneous cohort of patients undergoing surgical chronic subdural hematoma evacuation at our Institution. We also investigated whether the SHE score could reliably predict the occurrence of 30-day chronic subdural hematoma recurrence needing surgery. We included patients from our prospectively collected database from January 2018 to January 2021. Patients with the availability of the following information were enrolled: age, Glasgow Coma Scale score on admission, hematoma volume, medical history, and outcome at 30 days. The SHE score was calculated for each patient, and the association between greater scores and 30-day mortality was investigated and its ability to predict 30-day and disease recurrence. Statistical significance was assessed for P < 0.05. Three hundred twenty-one patients were included. Of them, 40 (12.5%) displayed mortality within 30-day: specifically, 0% of the group of patients with SHE score= 0, 4.3% of SHE score= 1, 14.5% of SHE score= 2, 39.3% of SHE score= 3, and 37.5% of SHE score= 4, with a statistically significant linear trend between greater SHE scores and 30-day mortality rates (P < 0.001, area under the curve 0.75 [0.67-0.82]). No significant association of the SHE score with the risk of recurrence needing surgery was detected (P= 0.4). The SHE score proved helpful in predicting 30-day mortality in patients with chronic subdural hematomas, but no utility was observed to predict disease recurrence.

Comparison of Outcome of Chronic Subdural Hematoma (SDH) In Terms of Recurrence with Drain and without Drain

Background/Objectives: Chronic subdural hematoma commonly reported in neurosurgical practices. Variations are reported in neurosurgical practices regarding the treatment of chronic subdural hematoma (SDH). This study determined the outcomes of SDH with Drain and without Drain in terms of recurrence and effectiveness.&#x0D; Material and Methods: A randomized control trial was conducted in the Department of Neurosurgery Ayub Teaching Hospital Abbottabad. Group-A patients were subjected to drainage of chronic subdural hematoma without drain and Group-B patients were subjected to drainage with drain. All patients were followed up to one month for recurrence of subdural hematoma like on CT-scan.&#x0D; Results: Overall, the recurrence of chronic subdural hematoma in both groups was seen in 16.7% of patients and the procedures were effective in 83.3% of patients. In Group A, 79.6% of patients were successfully treated through burr hole with irrigation, while 20.4% of patients had recurrent chronic SDH. In Group B, only 13% of patients had a recurrence, while 87% of patients were successfully treated with burr with the closed continuous drainage system. An insignificant difference (p-value: 0.302) existed between groups for both types of procedures.&#x0D; Conclusion: The patients who were treated with burr hole and irrigation of the subdural space with normal saline had high recurrence incidence than those with burr hole with closed continuous drainage system.

Postoperative neutrophil-to-lymphocyte ratio variation is associated with chronic subdural hematoma recurrence.

Chronic subdural haematoma (CSDH) is one of the most common neurosurgical pathologies. The recurrence of chronic subdural haematomas is an important concern, considering that elderly patients are the most affected and reoperations in these patients may represent a risk of neurological and clinical complications. In accordance with the inflammatory theory regarding CSDH and its recurrence, we aimed to evaluate the role of an inflammatory marker, neutrophil-to-lymphocyte ratio (NLR), as a risk factor and prognostic variable for CSDH recurrence. We performed a cohort study of adult patients operated for post-traumatic CSDH traumatic CSDH between January 2015 and December 2019 in our neurotrauma unit, whose data was retrospectively retrieved. We excluded patients with previous inflammatory or infectious diseases as well as use of anticoagulant/antiplatelet medications. Neutrophil and lymphocyte counts were obtained 24 h preoperatively and 48-72 h postoperatively. The primary endpoint was symptomatic recurrence of CSDH up to 1 year after the surgery. An independent sample was used to validate the findings. The testing sample comprised 160 patients (59.4% male, mean age 69.3 ± 14.3 years, recurrence rate 22.5%). Postoperative neutrophil count and NLR were higher in those who recurred, as well as the neutrophils (median 1.15 vs 0.96, p = 0.022) and NLR (median 1.29 vs 0.79, p = 0.001) postoperative-to-preoperative ratios. Preoperative laboratory parameters or other baseline variables were not associated with recurrence. Postoperative NLR ratio (each additional unit, OR 2.53, 95% CI 1.37-4.67, p = 0.003) was independently associated with recurrence. The best cut-off for the postoperative NLR ratio was 0.995 (AUC-ROC 0.67, sensitivity 63.9%, specificity 76.6%). Postoperative NLR ratio ≥ 1 (i.e. a post-operative NLR that does not decrease compared to the preoperative value) was associated with recurrence (OR 4.59, 95% CI 2.00-10.53, p < 0.001). The validation sample analysis (66 patients) yielded similar results (AUC-ROC 0.728, 95% CI 0.594-0.862, p = 0.002) and similar cut-off (≥ 1.05, sensitivity 77.8%, specificity 66.7%). NLR ratio can be a useful parameter for the prediction of post-traumatic CSDH recurrence. This hypothesis was validated in an independent sample and the accuracy was moderate.

Rise of the Double Crescent Sign as a Clinical Predictor of Chronic Subdural Hematoma Recurrence

Rise of the Double Crescent Sign as a Clinical Predictor of Chronic Subdural Hematoma Recurrence

Recurrence and Coniglobus Volumetric Resolution of Subacute and Chronic Subdural Hematoma Post-Middle Meningeal Artery Embolization.

Objective: To study the efficacy of middle meningeal artery (MMA) embolization for the treatment of chronic subdural hematoma (SDH) and characterize its post-embolization volumetric resolution. Methods: Ten patients diagnosed with 13 cSDH underwent MMA embolization. SDH volumes were measured from time of initial discovery on imaging to pre-operative, post-operative, short-term and long-term follow-up. Time between procedure to obliteration was also measured. Volumetric analysis was done using the coniglobus formula, and recurrence rate as well as resolution timeline was defined using best-fit models. Results: Out of 10 patients, five were recurrent lesions, three were bilateral and seven unilateral cSDH. Average and median pre-operative volumes were 105.3 cc and 97.4 cc, respectively. Embolization on average was performed 21 days after discovery. Sixty percent of patients had concurrent antiplatelets or anticoagulation use. Forty percent underwent embolization treatment as the primary therapy. Recurrence was not seen in any patients treated with embolization. There were no peri- or post-operative complications. Five patients experienced complete or near-complete obliteration, while those with partial resolution showed a composite average of 75% volumetric reduction in 45 days. Post-embolization, the volumetric resolution followed an exponential decay curve over time and was independent of initial volume. Conclusion: MMA embolization contributed to a marked reduction in SDH volume post-operatively and can be used as a curative therapy for primary or recurrent chronic SDH.

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

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

Prediction of chronic subdural hematoma recurrence by CT at 7 days post–surgery

Prediction of chronic subdural hematoma recurrence by CT at 7 days post–surgery

Preoperative neutrophil to lymphocyte ratio as a predictor of chronic subdural hematoma recurrence

Preoperative neutrophil to lymphocyte ratio as a predictor of chronic subdural hematoma recurrence

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.

Subdural Saline Irrigation as Treatment of Recurrent Subdural Hematoma After Drain Removal in a Patient with Spontaneous Intracranial Hypotension

Perez-Vega, Carlos; Robles-Lomelin, Pilar; Robles-Lomelin, Isabel; Diaz-Alba, Alexandra; Garcia-Navarro, Victor MD Author Information

Traumatic Brain Injury in the Elderly: Can We Reduce Readmissions? : A Community Hospital Experience.

Traumatic brain injury (TBI) is a leading cause of mortality and long-term morbidity in trauma patients, with a growing incidence among the elderly. Injury-related disability has many costs, and rehospitalization is a significant part of that. The current study was carried out in an elderly population with TBI to identify risk factors and measures associated with rehospitalization. We performed a retrospective analysis of 299 patients with a primary diagnosis of TBI admitted between 2016 and 2018. Variables selected for analysis encompassed the following: patient age, sex, comorbidities, diagnosis, length of stay, use of anticoagulants, 6-month readmission rate, and diagnosis for readmission. Chi-square analysis was used to identify potential risk factors, and multiple regression analysis was conducted to model the relationship. 209 patients met inclusion criteria, with a mean age of 69 years (SD ± 18.6 years), with (51.5%) males and (48.5%) females. 188 (62.9%) patients were on anticoagulant therapy. 120 patients were discharged to home (40.1%). 79 patients (26.4%) were readmitted within 6 months of discharge, the majority of whom (48 patients, 60.8%) presented with a subdural hematoma (SDH). 38 readmitted patients (49%) came from home, and 57 patients (80%) were on anticoagulant therapy. In elderly patients with TBI, discharge to a home setting correlates with a higher risk of readmission within 6 months, a majority with a diagnosis of recurrent SDH. Anticoagulant therapy and frequent past readmissions also correlated with a higher risk of subsequent readmission.

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.

Influence of Antithrombotic Medication on the Risk of Chronic Subdural Hematoma Recurrence after Burr-Hole Surgery.

ObjectiveChronic subdural hematoma (CSDH) is one of the most common intracranial hemorrhages. It can be managed with a simple surgical treatment such as burr-hole trephination and drainage. However, it has a relatively high recurrence rate. The mechanisms and risk factors for the recurrence have not yet been clearly identified and studies have reported varying results. MethodsWe analyzed 230 patients with CSDH who were treated with burr-hole trephination and drainage at our institution from March 2011 to March 2016. The patients were divided into recurrence and non-recurrence groups and the medical records of each group were used to analyze the risk factors associated with CSDH recurrence. ResultsAfter burr-hole trephination and drainage, CSDH recurrence was observed in 49 (21.3%) of the 230 patients. In univariate analysis, none of the factors showed statistical significance with respect to CSDH recurrence. In multivariate analysis, preoperative antithrombotic medication was the only independent risk factor for CSDH recurrence (odds ratio, 2.407; 95% confidence interval, 1.047–5.531). ConclusionThe present study found that preoperative antithrombotic medication was independently associated with CSDH recurrence.

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.

Specific causes and predictors of readmissions following acute and chronic subdural hematoma evacuation

Patients treated with craniotomy for subdural hematoma (SDH) evacuation have a higher readmission incidence when compared to other neurosurgical patients. Factors predictive of readmission following craniotomy for SDH are incompletely understood. The National Surgical Quality Improvement (NSQIP) database was queried for all patients treated by craniotomy for SDH of any etiology (e.g. acute, chronic, spontaneous, traumatic) during the study period (2012–2014). Patients requiring repeat hospitalization within 30 days of surgery were identified and classified by reason for readmission. Binary logistic regression analysis was used to identify predictors of readmission. 1024 patients met inclusion criteria, among whom 109 (10.6%) were readmitted within 30 days. The most common causes of readmission were recurrent SDH (n = 27; 33.3%), seizure (n = 8; 9.9%), new neurological deficit (n = 6; 7.4%), stroke (n = 6; 7.4%), and altered mental status (AMS) (n = 6; 7.4%). Multivariable modeling identified hypertension requiring medication (OR = 2.78, P = 0.013) and abnormal INR (OR = 2.66, P = 0.035) as significantly associated with readmission following chronic SDH, while postoperative UTI (OR = 3.64, P = 0.01) and stroke (OR = 4.86, P = 0.018) were significant predictors of readmission following acute SDH. Readmission was associated with recurrent hemorrhage after chronic/spontaneous SDH, while seizures, AMS, and neurological deficits drove readmissions after acute/traumatic SDH. Careful management of anticoagulation and antihypertensive medications may be helpful in reducing the risk of readmission following craniotomy for chronic SDH.