Subdural Hematoma Research Articles

Spontaneous Intracranial Hypotension and Dural Ectasia in Marfan Syndrome: An Illustrative Case Successfully Treated with Steroid Therapy and Literature Review

Background: Spontaneous intracranial hypotension (SIH) is a rare and frequently misdiagnosed disorder characterized by a low volume of cerebrospinal fluid (CSF) caused by the leakage of CSF through the spinal dural membrane. Patients with Marfan Syndrome (MS) and other connective tissue disorders are at an increased risk for dural ectasia, which may predispose them to spontaneous CSF leaks due to the structural weakness of their dural membranes. The management of SIH in MS patients is debated. Conservative measures, an epidural blood patch (EBP), and surgical treatments are the options generally provided. Methods: Herein, we report on the case of a 52-year-old female affected by MS, genetically confirmed, with a two-month history of sudden-onset, “thunderclap” headache, worsened in an upright position and horizontal diplopia. A Computed Tomography (CT) scan of the brain showed a bilateral chronic subdural hematoma, slit ventricles, and a caudal descent of the brainstem without overt tonsillar herniation. The Magnetic Resonance Imaging (MRI) scan of the whole spine revealed dural ectasia in the lumbosacral area and presacral perineural cyst without extradural CSF collection. The case was successfully managed with bed rest and high-dose corticosteroid therapy. Then, we discuss the pertinent literature, consisting of 25 papers dealing with the treatment of SIH in patients affected by MS. Results: The literature review yielded 25 papers dealing with SIH management in patients with MS, including 28 patients overall; 21 patients underwent EBP, of whom 7 patients had multiple procedures. Overall, in 23 cases (82%), the symptoms improved. In three cases, the patients were managed conservatively with bed rest. In three of these cases, there was an improvement. In one case, the surgical fenestration of two lumbar intradural spinal meningeal cysts was performed and the patient improved after the procedure. Our patient underwent 15 days of steroid therapy (dexamethasone iv 12 mg/day for 7 days, then reduced to 4 mg/day) and intravenous hydration (Ringer lactate 1500 mL/day). In ten days, the symptoms disappeared. At the 6-month follow-up, the patient was in good clinical condition, and a CT scan showed an almost complete regression of the bilateral subdural hematoma. Conclusions: The management of SIH in MS patients is still challenging. Patients with connective tissue disorders such as MS are at an increased risk for SIH. Few studies have assessed the management of these patients and different strategies. Our case and the available literature provide further data for this type of case.

Emergency neurosurgery for traumatic brain injury by general surgeons at local hospitals in Sweden: a viable option when time is brain.

Timing of surgical evacuation of mass lesions in traumatic brain injury (TBI) is crucial. However, due to geographical variations, transportation time to the nearest neurosurgical department may be long. To save time, general surgeons at a local hospital may perform the operation, despite more limited experience in neurosurgical techniques. This study aimed to determine whether patient outcomes differed between those who had undergone emergency neurosurgery at local hospitals by general surgeons vs. at university hospitals by neurosurgeons. A nationwide observational study was performed using data from the Swedish Trauma Registry (SweTrau) between 2018 and 2022. A total of 565 TBI patients (local hospitals, n = 21; university hospitals, n = 544) who underwent intracranial hematoma evacuation within 8h after arrival at the hospital were included. Data on demography, admission variables, traumatic injuries, and outcome (Glasgow Outcome Scale [GOS]) at discharge were evaluated. Favourable vs. unfavourable outcomes were defined as GOS scores of 4-5 vs. 1-3. Compared with those treated at university hospitals, patients treated with intracranial hematoma evacuation at local hospitals had lower median Glasgow Coma Scale (GCS) scores (8 vs. 12, p < 0.001), higher rate of acute subdural hematomas (86% vs. 77%, p < 0.001), and lower rate of contusions (14% vs. 53%, p = 0.01). Being operated on at a local hospital was independently associated with higher mortality (p = 0.03) but with a similar rate of favourable outcome (p = 0.74) in multiple logistic regressions after adjustment for demographic and injury-related variables. Although a slightly greater proportion of patients who underwent emergency neurosurgery at local hospitals died, there was no difference in the rate of favourable outcome. Thus, in patients with impending brain herniation, when time is of the essence, evacuation of traumatic intracranial bleeding by general surgeons at local hospitals remains a highly viable option.

RECENT DEVELOPMENTS IN ENDOVASCULAR THERAPY FOR CHRONIC SUBDURAL HEMATOMAS USING LIQUID EMBOLIC AGENTS

Chronic subdural hematomas (cSDH) remain a significant challenge in neurosurgery, particularly among the elderly. Recent advancements in endovascular therapy, specifically the use of non-adhesive embolic agents, have shown promise in improving outcomes for these patients. This presentation will delve into the latest developments and clinical evidence surrounding this innovative approach. The discussion will include findings from recent randomized trials that have evaluated the efficacy and safety of embolisation with non-adhesive agents, both as a standalone treatment and in conjunction with traditional surgical methods. Technical outcomes from these studies will be analyzed, highlighting key differences in patient recovery, complication rates, and long-term results between the combined and isolated approaches. One of the focal points of the presentation will be the technical nuances of performing embolisation, emphasizing the procedural intricacies and the choice of embolic materials. Comparative data will be presented to illustrate the benefits of non-adhesive agents over other embolisation methods, particularly in terms of reducing re-bleeding rates and minimizing invasive interventions. Additionally, we will explore future implications of widespread adoption of this technique, including its potential to alter standard care practices and improve patient prognoses. Projections will be made regarding the impact on healthcare resources, patient quality of life, and overall survival rates. The presentation aims to provide a comprehensive overview of the current state and future potential of endovascular therapy for cSDH, offering valuable insights for neurosurgeons and interventional radiologists seeking to enhance their therapeutic arsenal.

Commentary: Embolic Materials Comparison in Meningeal Artery Embolization for Chronic Subdural Hematomas: Multicenter Propensity Score-Matched Analysis of 1070 Cases

Commentary: Embolic Materials Comparison in Meningeal Artery Embolization for Chronic Subdural Hematomas: Multicenter Propensity Score-Matched Analysis of 1070 Cases

Use of dexamethasone in patients with chronic subdural hematoma: a systematic review

Use of dexamethasone in patients with chronic subdural hematoma: a systematic review

Abstract 4129839: Successful Left Atrial Appendage Occlusion (LAAO) with WATCHMAN FLX via Transhepatic Approach

Left atrial appendage occlusion (LAAO) with the WATCHMAN FLX (Boston Scientific) has been proven to reduce stroke risk in patients with paroxysmal atrial fibrillation (PAF). Certain circumstances may preclude LAAO1. In this case, transhepatic vein access was used to successfully deploy a WATCHMAN FLX in a 72 year old male with PAF not on anticoagulation due to recent subdural hemorrhage and recurrent bilateral lower extremity deep venous thrombosis (DVT) post IVC filter placement. Recent attempt at LAAO was unsuccessful due to total occlusion of bilateral femoral veins (Figure 1 A-B) and inability to cross the IVC. Access to the inferior branch of the right hepatic vein was achieved by micropuncture technique at the right mid-axillary line at the level of the 12th rib, which was confirmed by venogram (Figure 2A). The 4F microsheath was upsized to 16F. Intraoperative TEE was used for device sizing and delivery (Figure 3A). The transseptal sheath and dilator were positioned in the right atrium at the level of the fossa ovalis (Figure 3B) before successfully crossing into the left atrium (Figure 2B). After confirming placement (Figure 3C), a pigtail catheter was positioned within the LAA (Figure 3D) and an angiogram was performed (Figure 2C). A 24 mm WATCHMAN FLX was partially unsheathed and positioned (Figure 3E). Repeat LAA angiogram was performed through the WATCHMAN delivery sheath (Figure 2D). A Tug test was performed. The device was released (Figure 3F). Repeat venogram was performed to confirm location (Figure 2E) of the access site, and coil embolization closure of the venotomy access site was performed (Figure 2F). The patient was discharged the following day on dual antiplatelet (aspirin, clopidogrel) without complication. Venous access via right hepatic vein is a viable option for LAAO using the WATCHMAN FLX device.

CTNI-36. THE FEASIBILITY OF USING BORTEZOMIB WITH CHEMOTHERAPY IN ATYPICAL TERATOID/RHABDOID TUMORS

Abstract Atypical teratoid/rhabdoid tumors (ATRTs) are highly aggressive pediatric brain tumors with sensitivity to proteasome inhibitors in preclinical models. We evaluated the feasibility of combining the proteasome inhibitor bortezomib with chemotherapy. Patients aged 0-20 years with newly diagnosed ATRT were enrolled from January 2022 through December 2023. A modified Medical University of Vienna (MUV)-ATRT regimen was used. They were treated with bortezomib of 1.3 mg/m2/dose given intravenously or subcutaneously twice a week for 2 weeks concurrently with 6 cycles of chemotherapy and 2 additional cycles after high-dose chemotherapy. Radiation therapy was given prior to or at the end of chemotherapy. A total of 36 chemotherapy cycles with bortezomib in 6 patients were evaluated. The primary endpoint was grade 3 or higher non-hematologic toxicities. Numbers of cycles with grade 3+ toxicities included: AST/ALT elevation (1), hypokalemia (2), peripheral neuropathy (1), subdural hemorrhage (2), vomiting (2), oral mucositis (3), lung infection (2), urinary tract infection (8), sepsis (3), febrile neutropenia (20). No grade 3+ toxicities were considered bortezomib-related. Three patients completed 8 cycles of bortezomib treatment; 2 patients discontinued the study due to progressive disease after 2 and 4 cycles respectively; 1 patient completed 6 cycles of bortezomib and died of septic shock in complete remission after high-dose chemotherapy. Two patients had a surgical complete resection. Three patients were evaluable for response after bortezomib: 1 partial response and 2 stable disease. Two patients had progression-free survival for 16+ and 22+ months after diagnosis, respectively. Among the 3 patients with progressive disease, 2 had metastatic relapse and 1 had primary and metastatic relapse. There were 4 deaths due to metastatic PD (n=2), septic shock after high-dose chemotherapy (n=1), and septic shock after 2nd line treatment for PD (n=1). We conclude that adding bortezomib to standard and high-dose chemotherapy of ATRT was feasible with the occurrence of grade 3/4 toxicities no more than what was expected with chemotherapy alone. Metastatic relapse remains the major challenge of ATRT treatment.

Recurrent Subdural and Epidural Hematomas: A Case Report of Complications Following Craniotomy and Middle Meningeal Artery Embolization

Recurrent Subdural and Epidural Hematomas: A Case Report of Complications Following Craniotomy and Middle Meningeal Artery Embolization

Clinical practice guidelines for the care of patients with a chronic subdural haematoma: multidisciplinary recommendations from presentation to recovery

Introduction A chronic subdural haematoma (cSDH) is an encapsulated collection of fluid and blood degradation products in the subdural space. It is increasingly common, affecting older people and those living with frailty. Currently, no guidance exists to define optimal care from onset of symptoms through to recovery. This paper presents the first consensus-built recommendations for best practice in the care of cSDH, co-designed to support each stage of the patient pathway. Methods Guideline development was led by a multidisciplinary Steering Committee with representation from diverse clinical groups, professional associations, patients, and carers. Literature searching to identify relevant evidence was guided by core clinical questions formulated through facilitated discussion with specially convened working groups. A modified Delphi exercise was undertaken to build consensus on draft statements for inclusion in the guideline using survey methodology and an in-person meeting. The proposed guideline was subsequently endorsed by the Society for British Neurological Surgeons, Neuroanaesthesia and Critical Care Society, Association of Anaesthetists, British Association of Neuroscience Nurses, British Geriatric Society, and Centre for Perioperative Care. Results We identified that high quality evidence was generally lacking in the literature, although randomised controlled trial (RCT) data were available to inform specific recommendations on aspects of surgical technique and use of corticosteroids. The final guideline represents the outcome of synthesising available evidence, consensus-built expert opinion and patient involvement. The guideline comprises 67 recommendations across eight major themes, covering: presentation and diagnosis, neurosurgical triage and shared decision-making, non-operative management, perioperative management (including anticoagulation), timing of surgery, intraoperative and postoperative care, rehabilitation and recovery. Conclusions We present the first multidisciplinary guideline for the care of patients with cSDH. The recommendations reflect a paradigm shift in the care of cSDH, recognising and formalising the need for multidisciplinary and collaborative clinical management, communication and decision-making delivered effectively across secondary and tertiary care.

Examining the standalone efficacy and safety of tranexamic acid in chronic subdural hematoma: a comprehensive review and meta-analysis

BackgroundChronic subdural hematoma (CSDH) is an important medical condition characterized by the accumulation of blood in the subdural space. Several methods have been explored, including surgical intervention and administration of tranexamic acid, which is a conservative treatment option. This meta-analysis aimed to assess the effectiveness and safety of tranexamic acid in CSDH management.MethodsA systematic literature search was performed according to the PRISMA and MOOSE guidelines. This study included cohort and randomized controlled trials involving adults with chronic subdural hematoma (CSDH) who were treated with intravenous tranexamic acid. The primary outcome measures were recurrence and adverse events.ResultsSix studies encompassing 2024 participants were included. Studies have shown that tranexamic acid reduced recurrence rates (OR, 0.32; 95% CI: 0.27–0.38, p = 0.16; I2 = 0%), although the result was non-significant. However, the analysis of adverse events indicated a moderate level of heterogeneity (OR, 1.14; 95% CI: 0.60–2.15, p = 0.07; I2 = 57%), suggesting a potential safety concern.ConclusionIn conclusion, this meta-analysis suggests tranexamic acid (TXA) may reduce chronic subdural hematoma (CSDH) recurrence, though significance varied across studies. Adverse effects with TXA were similar to controls. Larger trials are needed to confirm TXA’s role in CSDH management.

Chronic Subdural Hematomas—A Retrospective Analysis of the Internal Architecture and Evaluation of Risk Factors for Recurrences After Surgical Therapy

Background: Chronic subdural hematoma (CSDH) is increasingly common due to the aging population and widespread use of anticoagulant and antiplatelet medications. The objective of this study is to examine the internal composition of CSDH and explore potential risk factors associated with its recurrence. Methods: This retrospective study analyzed data from 189 patients who underwent surgery in our department between 2014 and 2018. Recorded data included demographics, clinical information, details of surgical interventions, computer tomography (CT) scans, neurological assessments, and follow-up data. The outcome was evaluated clinically and through CT follow-up conducted 4–12 weeks post-surgery. CT scans measured various parameters, including hematoma thickness, hyperdense regions, chronic components, and membrane presence. Results: Patients after the evacuation of CSDH were significantly more common males (66.1%, p &gt; 0.001) had a significantly higher BMI (p &lt; 0.001, 61.6%), arterial hypertension (p &lt; 0.001, 68.3%), and the intake of anticoagulant therapy (p &lt; 0.001, 58%). The recurrence rate was 18.6% after 4 weeks and 2.1% after 8–12 weeks. After uni- and multivariable analysis, the initial hemispheric type (p = 0.019, HR: 3.191; p = 0.012, HR: 3.810) and the increasing preoperative midline shift in CT (p = 0.028, HR: 1.114; p = 0.041, HR: 1.107) were found as independent predictors for recurrence. Overall, outcomes were favorable with a modified Rankin scale (mRS) of 0–2 at discharge (72%), after 4 (89.7%) and 12 (87%) weeks. Conclusion: According to our data, increasing midline shift before surgery and initial hemispheric type of hematoma were independent predictors of recurrence. Most patients achieved an excellent outcome with a low-risk profile.

Onyx dilution reduces time to resolution of chronic subdural hematomas after middle meningeal artery embolization

BackgroundThe benefit of distal embolite penetration for middle meningeal artery (MMA) embolization in chronic subdural hematomas (cSDH) remains controversial.ObjectiveTo compare the use of diluted Onyx with undiluted Onyx in the...

Research on imaging biomarkers for chronic subdural hematoma recurrence.

This study utilizes radiomics to explore imaging biomarkers for predicting the recurrence of chronic subdural hematoma (CSDH), aiming to improve the prediction of CSDH recurrence risk. Analyzing CT scans from 64 patients with CSDH, we extracted 107 radiomic features and employed recursive feature elimination (RFE) and the XGBoost algorithm for feature selection and model construction. The feature selection process identified six key imaging biomarkers closely associated with CSDH recurrence: flatness, surface area to volume ratio, energy, run entropy, small area emphasis, and maximum axial diameter. The selection of these imaging biomarkers was based on their significance in predicting CSDH recurrence, revealing deep connections between postoperative variables and recurrence. After feature selection, there was a significant improvement in model performance. The XGBoost model demonstrated the best classification performance, with the average accuracy improving from 46.82% (before feature selection) to 80.74% and the AUC value increasing from 0.5864 to 0.7998. These results prove that precise feature selection significantly enhances the model's predictive capability. This study not only reveals imaging biomarkers for CSDH recurrence but also provides valuable insights for future personalized treatment strategies.

The impact of early surgery on mortality and functional recovery in older adults with traumatic intracranial lesions: a propensity score-based analysis.

There is skepticism about the benefit of surgery in elderly patients affected by traumatic brain injury (TBI) due to the negative effect of age on the outcome and surgical complications. However, there are few studies that have investigated differences in patient's outcome between surgically and conservatively managed patients after adjusting for the imbalance in preinjury characteristics and clinical and radiological features. The primary aim of this study was to evaluate the effect of early surgery on mortality and functional recovery in a cohort of older adults with acute traumatic intracranial lesions after adjustment by Propensity Score (PS) matching. MATERIALS AND METHODS: We conducted a retrospective cohort study on older adult patients (≥ 65 years) admitted for TBI between 2013 and 2023 to a single level 1 trauma center. Patients were categorized based on whether they underwent early surgery (< 48h after TBI) for a space-occupying lesion evacuation. PS model was constructed based on age, frailty, comorbidities (Charlson comorbity index and American Society of Anaesthesiologists score), anticoagulants, hypoxia, shock, pupillary abnormalities and GCS motor response upon admission, midline shift, basal cistern effacement, volume of subdural and intracerebral hematomas, and limitation of life-sustaining treatment decisions.The effect of early surgery on 30-day mortality and unfavorable functional outcomes (GOSE 1-3) at 6 and 12 months were investigated after matching by paired test. We identified and reviewed 301 patients who met all inclusion criteria and contained no exclusions. After matching, 62 patients (31 pairs of conservative and surgical patients) remained as the matched datasets. Our key finding was that older adult TBI patients who underwent early surgery had a statistically significant reduction in the risk of 30-day mortality (OR 0.313, 95% CI 0.114-0.853, p = 0.023) and unfaourable outcome at 12 months after TBI (OR 0.286, 95% CI 0.094-0.868, p = 0.027). Early surgery was associated with decreased 30-day mortality and better functional outcome at 12 months after TBI in older adults with few comorbidities and good functionality when clinically affected by acute traumatic intracranial lesions with mass effect.

Middle meningeal artery embolization and tranexamic acid therapy for subdural hematoma in a patient with hereditary hemorrhagic telangiectasia: illustrative case.

Subdural hematoma is a rare manifestation of hereditary hemorrhagic telangiectasia (HHT), also known as Osler-Weber-Rendu disease. Here, the authors present a patient with HHT and a large chronic subdural hematoma, for whom nonsurgical management was pursued. A 49-year-old right-handed male with a history of hypertension and familial HHT presented with complaints of mild confusion and left hemiparesis over several days. Noncontrast head computed tomography images demonstrated a large chronic right hemisphere subdural hematoma compressing the right cerebral hemisphere and causing a 1.3-cm midline shift. Due to concerns about surgical complications arising from hemorrhages of cryptic telangiectasias, the patient was treated conservatively with middle meningeal artery embolization and adjuvant tranexamic acid. There was clinical and radiological resolution several months later. This case highlights the rarity of a subdural hematoma as a manifestation of HHT and the nonsurgical treatment strategy as a mechanism to avoid hemorrhagic complications of surgical evacuation. https://thejns.org/doi/10.3171/CASE24483.

Development and Validation of a Novel Classification System and Prognostic Model for Open Traumatic Brain Injury: A Multicenter Retrospective Study.

Open traumatic brain injury (OTBI) is associated with high mortality and morbidity; however, the classification of these injuries and the determination of patient prognosis remain uncertain, hindering the selection of optimal treatment strategies. This study aimed to develop and validate a novel OTBI classification system and a prognostic model for poor prognosis. This retrospective study included patients with isolated OTBI who received treatment at three large medical centersin China between January 2020 and June 2022 as the training set. Data on patients with OTBI collected at the Fuzong Clinical Medical College of Fujian Medical University between July 2022 and June 2023 were used as the validation set. Clinical parameters, including clinical data at admission, radiological and laboratory findings, details of surgical methods, and prognosis were collected. Prognosis was assessed through a dichotomized Glasgow Outcome Scale (GOS). A novel OTBI classification was proposed, categorizing patients based on a combination of intracranial hematoma and midline shift observed on imaging, and logistic regression analyses were performed to identify risk factors associated with poor prognosis and to investigate the association between the novel OTBI classification and prognosis. Finally, a nomogram suitable for clinical application was established and validated. Multivariable logistic regression analysis identified OTBI classification type C (p<0.001), a Glasgow Coma Scale score (GCS)≤8 (p<0.001), subarachnoid hemorrhage (SAH) (p=0.004), subdural hematoma (SDH) (p=0.011), and coagulopathy (p=0.020) as independent risk factors for poor prognosis. The addition of the OTBI classification to a model containing all the other identified prognostic factors improved the predictive ability of the model (Z=1.983; p=0.047). In the validation set, the model achieved an area under the curve (AUC) of 0.917 [95% confidence interval (CI)=0.864-0.970]. The calibration curve closely approximated the ideal curve, indicating strong predictive performance of the model. The implementation of our proposed OTBI classification system and its use alongside the other prognostic factors identified here may improve the prediction of patient prognosis and aid in the selection of the most suitable treatment strategies.

Dynamic Craniotomy With Khanna NuCrani Plates as an Alternative to Craniotomy With Fixed Plates in Traumatic Brain Injury.

Dynamic craniotomy as opposed to a fixed plate craniotomy provides cranial decompression with a controlled outward bone flap movement to accommodate postoperative cerebral swelling and/or hemorrhage. The objective of this study was to evaluate if fixation of the bone flap following a trauma craniotomy with dynamic plates provides any advantage over fixed plates. A review of our clinical series of 25 consecutive adult patients undergoing dynamic craniotomy with the Khanna NuCrani reversibly expandable bone flap fixation plates for the treatment of traumatic brain injury associated with mass lesions including subdural, epidural, and cerebral hematomas was conducted. Postoperative cerebral swelling was encountered in 21 of 25 patients (84%), which was compensated for with outward bone flap movement in all these patients and associated decreased midline shift. Severe brain swelling with outward bone flap movement of 8 mm or more was noted in 40% of the patients. All patients had a normal intracranial pressure after surgery. None of the patients required any reoperations for hematoma evacuation, rescue decompressive craniectomies, cranioplasty, or complications related to wound healing. The bone flap retracted after the resolution of the brain swelling, and none of the patients reported cosmetic symptoms related to bone flap or wound healing. Overall, 84% (21 of 25) of the patients achieved a good outcome. Craniotomy bone flap fixation with dynamic plates is an alternative to craniotomy with fixed plates. The main advantage of dynamic craniotomy over a craniotomy with fixed plates is that it allows for immediate intracranial volume expansion with reversible outward bone flap migration in patients who may develop postoperative worsening brain swelling and/or hemorrhage, with decreased need for repeat surgeries and associated complications.

Decompressive craniectomy versus craniotomy for acute subdural hematoma: A systematic review and meta-analysis with an adjusted subgroup analysis.

Acute subdural hematomas are major causes of morbidity which warrant immediate treatment. If surgical intervention is warranted, craniotomy (CO) and decompressive craniectomy (DC) are employed, largely based on a loosely defined criteria and the neurosurgeon's best judgment. The primacy of one approach over another is a matter of dispute. We attempt to further clarify any advantages in the two techniques, and include a propensity score matched (PSM) subgroup analysis to eliminate bias. This meta-analysis was conducted following the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. A literature review was conducted on PubMed/Medline, Cochrane Central, and Google Scholar from inception to September 2023. 15 studies were extracted, and three outcomes were meta-analyzed: Mortality, Glasgow Outcome Scale (GOS) scores and patients undergoing re-operations/revisions. Odds Ratios (OR) and Mean Difference (MD) were used in dichotomous and continuous variables respectively. PSM data was used wherever possible. A subgroup analysis was conducted with 5 PSM studies and a trial. Heterogeneity was addressed if above 40% and the P-value is significant (≤ .05). A total of 15 studies were meta-analyzed with a total of 2327 and 2171 patients undergoing CO and DC respectively. Patients undergoing DC had a significantly worse GOS 5 outcome (OR: .63 [95% CI: .45-.87]; P = .005; I2 = 0%) and higher mortality (OR: 1.58 [95% CI: 1.20-2.08]; P = .001; I2 = 67%). In subgroup analysis of adjusted studies, DC still had significantly higher mortality. (OR: 1.50 [95% CI: 1.03-2.18]; P = .001; I2 = 83%). This meta-analysis determines that CO is more viable than DC as a surgical option due to its less invasive nature. DC can be employed, albeit under strict preprocedural patient selection and for highly specific indications.

Inflammatory Risk Factors for Chronic Subdural Hematoma in a Nationwide Cohort.

The discovery of biomarkers in chronic subdural haematomas (CSDH) suggests that inflammation is part of CSDH pathophysiology. It is unknown whether inflammation reflects an independent CSDH driver or haematoma degeneration. This knowledge holds a potential target for anti-inflammatory treatment in patients at risk of CSDH. This study investigated the association of pro- and anti-inflammatory factors with CSDH development. This cohort study included all individuals in Denmark over 50 years between 2007-2018. The outcome was first-time CSDH surgery. Hazard ratios (HR) according to potential risk factors were estimated using Cox regression, with age as underlying time scale. Among the 2,391,853 individuals, head trauma was registered in 427,612 individuals (17%), and among these, only 812 were operated for CSDH (0.18%). Among individuals without registered head trauma, the pro-inflammatory conditions of alcohol addiction, diabetes, anti-hypertensive treatment, and chronic hepatic disease were significantly associated with CSDH among individuals (50-74 years). The use of glucocorticoids displayed a decreased risk in cohort members aged 75 and older. Non-steroid anti-inflammatory drugs and statins appeared to be risk factors for CSDH in individuals between the ages of 50-64 and 65-74. Although head trauma was a risk factor for CSDH, the absolute risk was low (0.18%), which does not support preventive measures after emergency room contacts for head trauma. Interestingly, pro-and anti-inflammatory factors were significantly associated with CSDH in patients without registered head trauma, and the pronounced age-dependency of the associations suggests that the pathophysiological mechanisms vary with age.

A unique case of Sylvian arachnoid cyst complicated by chronic subdural hematoma

Background: Arachnoid cysts (ACs) complicated by chronic subdural hematoma (CSDH) are a rare but distinct entity. Case Description: A 27-year-old man previously diagnosed with Sylvian AC presented to the hospital with a persistent headache. He was not aware of any preceding head trauma. However, he frequently performed bench presses at the gymnasium, especially 4 weeks prior. The patient did not exhibit any neurological deficits at presentation. Computed tomography revealed slightly low-density areas in the right cerebral convexity. Magnetic resonance imaging revealed compressive masses in the right middle fossa and cerebral convexity. The patient underwent a craniotomy. Reflection of the dura mater exposed thickened arachnoid membrane. Making an incision resulted in the egress of fluid hematoma. The membrane separating the subdural hematoma and inner AC possessed fine vasculature and adjacent holes. Furthermore, there were fragile clots adhered to the inner wall of the cyst. Microscopic findings of the separating membrane were consistent with inflammatory granulation tissue, similar to those of the outer membrane of CSDH. Conclusion: Exertional hypertension associated with the bench press may result in the rupture of fine arteries distributed over the AC wall. Under certain circumstances, the AC wall may transform into the outer membrane of CSDH.