Treatment Of Chronic Subdural Hematoma Research Articles

Efficacy analysis of neuroendoscopy-assisted burr-hole evacuation for chronic subdural hematoma: a systematic review and meta-analysis.

The purpose of this study was to compare neuroendoscopy-assisted burr-hole evacuation with conventional burr-hole evacuation in the treatment of chronic subdural hematoma (CSDH), and to evaluate the curative effect of neuroendoscopy. This study follows PRISMA guidelines and uses the keywords "chronic subdural hematoma," "neuroendoscopies," "neuroendoscopy," "endoscopy," "endoscopic neurosurgery," and "neuroendoscopic surgery" to conduct an electronic search of online databases, including PubMed, Embase, Web of Science, and Cochrane Library. There were no restrictions on language or publication year. This meta-analysis involved 948 patients in six studies. The results showed that the recurrence rate in the neuroendoscopy group was significantly lower than that in the conventional burr-hole group (3.1% vs. 13.8%, P<0.001). Compared with the control group, the neuroendoscopy group had a longer operation time (P<0.001) and a shorter postoperative drainage time (P<0.001). In addition, there was no significant difference in hospital stay (P=0.14), mortality (P=0.39), postoperative morbidity (P=0.12), or 6-month neurological outcomes (P=0.32) between the two groups. It should be noted that the comparison of neurological outcomes was based on 269 patients (6/106 vs. 14/163). Compared with conventional burr-hole evacuation, neuroendoscopy-assisted burr-hole evacuation reduces the recurrence rate of CSDH and shortens the postoperative drainage time. However, the neuroendoscopy group did not have lower mortality or morbidity or better functional outcomes. In the future, randomized controlled trials are needed to further evaluate the efficacy and safety of neuroendoscopic surgery.

Comparison of the Burr Hole Craniostomy Techniques for the Treatment of Chronic Subdural Hematoma

Objective: To compare three different surgical techniques for chronic subdural hematoma (CSDH), one of the most common neurosurgical diseases increasingly affecting the elderly, and for which there is no standard treatment currently. Material and Methods: We included 28 patients diagnosed with CSDH and retrospectively analysed their data. The surgical techniques were compared to subgroups of the burr-hole craniostomy technique. Results: The mean age of included patients was 72.71 ± 10.81 years, and the male/female ratio was 2/5. Preoperative subdural hematoma volume was 113.63 ± 40.74 cc, and the Hounsfield unit value was 33.66 ± 8.67 HU. The mean operative time was 60.89 ± 20.04 min, and the mean hospital stay was 6.17 ± 2.56 days. Detectable radiologic complete recovery was 42.69 ± 17.46 days. Conclusion: All surgery subgroups experienced successful outcomes during long-term follow-up. The irrigation technique demonstrated no superiority to the other two techniques and the complication rate was significantly lower with the endoscopic technique

Effectiveness of Burr Hole Sizes on Midline Shift and Hematoma Thickness in the Treatment of Chronic Subdural Hematoma

The aim of our study was to investigate the effect of the burr hole width on the postoperative chronic subdural hematoma (CSH) thickness and midline shift radiologically. The medical records of 92 patients who had undergone surgery after a diagnosis of CSH between April 1, 2015 and July 1, 2021 were reviewed retrospectively. Preoperative and postoperative computed tomography (CT) scans were reviewed, and the thickness of the hematoma and midline shift and the diameters of 2 burr holes opened were measured and recorded. The correlation between the burr hole diameter width and CSH thickness on postoperative CT scans and the improvement in midline shift were investigated statistically. When the CT scans performed on the first postoperative day and first postoperative month were examined, we found that the preoperative hematoma thickness and midline shift were significantly reduced postoperatively (P < 0.001). A positive significant correlation was found between the improvement in the midline shift, posterior burr hole diameter, and anteroposterior burr hole arithmetic mean (P < 0.001 and P= 0.029, respectively). Having examined the current surgical techniques in the treatment of CSH, we found that an increase in the burr hole craniostomy width, especially the posterior burr hole craniostomy width, contributed to the improvement in the midline shift.

Middle Meningeal Artery Embolization for Chronic Subdural Hematoma: Predictors of Clinical and Radiographic Failure from 636 Embolizations.

Background Knowledge regarding predictors of clinical and radiographic failures of middle meningeal artery (MMA) embolization (MMAE) treatment for chronic subdural hematoma (CSDH) is limited. Purpose To identify predictors of MMAE treatment failure for CSDH. Materials and Methods In this retrospective study, consecutive patients who underwent MMAE for CSDH from February 2018 to April 2022 at 13 U.S. centers were included. Clinical failure was defined as hematoma reaccumulation and/or neurologic deterioration requiring rescue surgery. Radiographic failure was defined as a maximal hematoma thickness reduction less than 50% at last imaging (minimum 2 weeks of head CT follow-up). Multivariable logistic regression models were constructed to identify independent failure predictors, controlling for age, sex, concurrent surgical evacuation, midline shift, hematoma thickness, and pretreatment baseline antiplatelet and anticoagulation therapy. Results Overall, 530 patients (mean age, 71.9 years ± 12.8 [SD]; 386 men; 106 with bilateral lesions) underwent 636 MMAE procedures. At presentation, the median CSDH thickness was 15 mm and 31.3% (166 of 530) and 21.7% (115 of 530) of patients were receiving antiplatelet and anticoagulation medications, respectively. Clinical failure occurred in 36 of 530 patients (6.8%, over a median follow-up of 4.1 months) and radiographic failure occurred in 26.3% (137 of 522) of procedures. At multivariable analysis, independent predictors of clinical failure were pretreatment anticoagulation therapy (odds ratio [OR], 3.23; P = .007) and an MMA diameter less than 1.5 mm (OR, 2.52; P = .027), while liquid embolic agents were associated with nonfailure (OR, 0.32; P = .011). For radiographic failure, female sex (OR, 0.36; P = .001), concurrent surgical evacuation (OR, 0.43; P = .009), and a longer imaging follow-up time were associated with nonfailure. Conversely, MMA diameter less than 1.5 mm (OR, 1.7; P = .044), midline shift (OR, 1.1; P = .02), and superselective MMA catheterization (without targeting the main MMA trunk) (OR, 2; P = .029) were associated with radiographic failure. Sensitivity analyses retained these associations. Conclusion Multiple independent predictors of failure of MMAE treatment for chronic subdural hematomas were identified, with small diameter (<1.5 mm) being the only factor independently associated with both clinical and radiographic failures. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Chaudhary and Gemmete in this issue.

Clinical efficacy of minimally invasive puncture and drainage versus trepanation and drainage for chronic subdural hematoma: Systematic review and meta-analysis.

This study aimed to evaluate the clinical efficacy of minimally invasive puncture and drainage (MIPD) versus trepanation and drainage in the treatment of chronic subdural hematoma (CSDH). PubMed, EMBASE, Cochrane Library, China National Knowledge Infrastructure, and Wanfang database were searched for studies on the treatment of CSDH by MIPD and trepanation and drainage. By reading the title, abstract and full text, and screening according to the inclusion and exclusion criteria, the qualified articles were confirmed. Subsequently, the literature quality was evaluated based on the Cochrane Handbook for Systematic Reviews of Interventions, and the data of the research subjects and the primary outcome measures were extracted for meta-analysis with RevMan 5.1 software. Ten articles were included, with a total of 1000 patients. According to the meta-analysis, the 2 groups showed no statistical difference in CSDH recurrence rate (P > .05). The operation time, intraoperative blood loss, and incidence of postoperative adverse reactions were lower and the cure rate was higher in the MIPD group compared with trepanation and drainage group (all P < .05). By drawing the funnel plot of the outcome measures with heterogeneity, it can be seen that the distribution on both sides of the funnel was basically symmetrical, suggesting a low deviation possibility of the analysis results and reliable reference significance of our findings. Compared with trepanation and drainage, MIPD has better clinical effects and higher safety in treating CSDH and can effectively reduce surgery-induced damage, which is worth popularizing in clinical practice.

Surgical treatment for chronic subdural hematoma in the elderly: A retrospective analysis

BackgroundChronic subdural hematoma (CSDH) is primarily a disease of the elderly. Less invasive interventions are often offered for elderly (> 80 years) patients due to concerns for elevated surgical risk, although data suggesting a clear outcome benefit is lacking. MethodsAll patients aged 65 years or older who underwent surgical treatment for CSDH at a single institution over a 4-year period were evaluated in this retrospective analysis. Surgical options included twist drill craniostomy (TDC), burr hole craniotomy (BHC), or standard craniotomy (SC). Outcomes, demographics, and clinical data were collected. Practice patterns and outcomes for patients older than 80 years old were compared to the age 65-80 cohort. Results110 patients received TDC, 35 received BHC, and 54 received SC. There was no significant difference in post-operative complications, outcomes, or late recurrence (30-90 days). Recurrence at 30 days was significantly higher for TDC (37.3% vs. 2.9% vs 16.7%, p 80 group, SC had higher risk of stroke and increased length of stay. ConclusionTwist drill craniostomy, burr hole craniostomy, and standard craniotomy have similar neurologic outcomes in elderly patients. Presence of thick membranes is a relative contra-indication for TDC due to high 30-day recurrence. Patients > 80 have higher risk of stroke and increased length of stay with SC.

Time and Influencing Factors to Chronic Subdural Hematoma Resolution After Middle Meningeal Artery Embolization

We sought to describe the resolution time of chronic subdural hematoma (CSDH) after middle meningeal artery embolization (MMAE) and potential variables that may affect hematoma resolution. A retrospective analysis was performed on CSDH patients between December 2018 and December 2021. Patient characteristics, radiologic manifestations, and data of hematoma resolution were recorded. Univariate and multivariate analyses were conducted to identify predictors of CSDH resolution time. A total of 53 patients were enrolled including 53 hematomas. Only 1 participant relapsed and did not require surgical evacuation. Hematoma resolution was observed in 27 (50.9%) at 4 months and 48 (90.6%) cases at the last radiologic follow-up. The median MMAE-to-resolution time was 19 weeks (interquartile range: 8-24). The burr-hole irrigation+ MMAE group showed faster hematoma resolution than MMAE alone during early follow-up periods, but no significant difference was found at 6 months. Increased thickness of residual hematoma, excessive postoperative midline shift, high-density hematoma, mixed-density hematoma, separated hematoma, and anticoagulant or antiplatelet agents used were predictive of nonresolution at 4 months as determined by univariate analysis, whereas anticoagulant or antiplatelet agents used and high-density hematoma were not significant on multivariate analysis. No significant association was noted between hematoma resolution and comorbidities or other hematoma radiologic features. MMAE is an effective and minimally invasive treatment for CSDH with a lower recurrence rate. The median resolution time of CSDH following MMAE was 19 weeks (interquartile range: 8-24). Burr-hole irrigation contributed to early hematoma resolution but had no significant effect at 6 months. In addition, residual hematoma thickness, postoperative midline shift, and specific type of hematoma were associated with delayed hematoma resolution at 4 months.

Single Frontal Burr-Hole Craniostomy Under Local Anesthesia for Treating Chronic Subdural Hematoma in the Septuagenarians and Older Adults: Surgical Technique and Results

Abstract Background Chronic subdural hematoma (CSDH) is not a totally benign disease in the elderly patients, especially those aged 70 years and above. Hence, the surgical treatment of CSDH in aged patients needs to be as minimally disruptive as possible. Methods An annotated description of the surgical technique of single frontal burr-hole craniostomy performed under local anesthesia and without closed tube drainage for evacuating CSDH in the septuagenarians and older adults is given. We also review the outcome of the procedure on a prospective consecutive cohort of patients in our service Results Thirty patients, 25 males, aged 70 years and above successfully underwent this surgical procedure. Their mean age was 76.5 years (standard deviation, 4.3). The CSDH was bilateral in 30% (9/30), and more left sided in the rest, the unilateral cases, and was of mixed density radiologically, in most cases (73%, 22/30). Clinical presentation was mainly gait impairment, cognitive decline, and headache, and 57% (17/30) presented with coma or stupor as assessed by the Markwalder grading scale.The surgery was successfully executed in all, median duration 45.0 minutes (interquartile range 37.3–60.0), and solely under local anesthesia in 77% (23/30) or with momentary short-acting sedation in the rest. The outcome was very good in 90.0% (27/30) using the modified Rankin Scale (mRS) including two-third (20/30) completely asymptomatic (mRS 0) and 7/30 with only slight symptoms/disability, mRS ≤ 2. Three patients died perioperatively, all presenting in coma. Conclusion This surgical technique appears very effectual for CSDH, is executed at a comparatively low cost, and, being much less disruptive than other traditional methods, may be a more homeostatic operative treatment in geriatric patients at least.

Abstract Number ‐ 39: Comparison of Clinical and Radiographic Efficacy of Particles versus nBCA/Onyx in MMA Embolization for cSDH

Introduction Middle meningeal artery (MMA) embolization has emerged as a minimally invasive alternative to open surgery for treatment of chronic subdural hematoma (cSDH). Different embolic materials are utilized in this procedure per operators’ discretion; however, limited data currently exists regarding the clinical and radiographic efficacy of these embolic materials, with available studies lumping Onyx and N‐Butyl cyanoacrylate (n‐BCA) into a single group of liquid embolic material. Methods Series of consecutive patients undergoing MMA embolization (MMAE) for cSDH at 2 North American centers (2019‐2021) were included. The primary outcomes included cSDH radiographic resolution of cSDH with at least 50% reduction of hematoma thickness to be considered treatment success. Clinical outcomes were defined as the proportion of patients requiring additional unplanned surgical intervention. These outcomes compared between the particles group, the liquid group which were further subdivided into the n‐BCA and Onyx groups. Results Overall, 185 patients undergoing 198 MMAE procedures (median age 72 years, 27.5% women) were included in this analysis. In this cohort, 42.6% of the procedures were performed utilizing particles embolic material, while n‐BCA and Onyx were utilized in 29.5% and 26.8% of procedures, respectively. On last follow‐up imaging (median 3.5 months), ≥ 50% reduction in hematoma thickness was achieved in 67.7%, 71.1%, and 72.3% in the particles, Onyx and the n‐BCA group, respectively (p = 0.2). There were no differences in the proportion of patients requiring additional unplanned surgery between the groups (p = 0.6). Similarly, there was no difference in procedural complications between the 3 embolic materials groups. Conclusions MMAE for cSDH utilizing particles and liquid embolic materials (including Onyx and n‐BCA) appears to have an overall equivalent safety and efficacy profiles in cSDH treatment. Further studies with larger sample sizes and longer follow‐up are warranted.

Abstract Number ‐ 101: Blood Pressure Interventions Are Most Common Reason for ICU Admission After MMA Embolization

Introduction Middle meningeal artery embolization (MMAE) is a minimally invasive technique that is increasingly performed for the treatment of chronic subdural hematomas. In comparison to prior surgical interventions, which often resulted in complications such as insufficient drainage or recurrence of rebleeding, MMAE has greatly reduced the need for multiple inpatient hospitalizations. Some authors have described managing minimally symptomatic patients with MMAE in the outpatient setting. Our practice, however, has been routinely admitting patients to the neuro‐intensive care setting after MMAE. The objective of this research is to analyze the frequency of ICU level interventions that were administered to patients after MMAE in the neuro‐intensive care unit in order to gain a better understanding of postoperative management and assess the potential for future management in the outpatient setting. Methods A consecutive series of MMA embolizations for cSDH were retrospectively reviewed from 2020 to 2022 at Valley Baptist Medical Center in Harlingen, TX, USA. Frequency of ICU specific interventions such as need for post procedural mechanical ventilation, need for intravenous vasopressor or antihypertensive medications was recorded. Additional data collected included patient clinical presentations, indications for treatment, additional neurosurgical intervention, length of ICU stay, and blood pressure parameters. Results A total of 50 MMA embolizations were performed during the study period. The average age of patients included in the study was 63 years old +/‐ 16 years with 30% being female. 34% patients did not receive any sort of ICU level intervention at all. Among the remaining who did, 32% required mechanical ventilation post procedurally. 14% needed a vasopressor and 48% required intravenous antihypertensives to maintain systolic blood pressure within goal parameters. Conclusions The most common reason for an ICU intervention after MMAE was for correction of blood pressure to maintain within specified goal. 34% of patients who underwent MMAE did not require any ICU level interventions afterwards. Further investigation is warranted, but current data suggests that liberalizing blood pressure parameters could potentially reduce the need for ICU utilization after MMAE. Assessment of various components of ICU level interventions administered to patients post‐MMAE allows for a better understanding on preventive measures that can be taken in the future to reduce length of inpatient stay post procedurally, which would reduce risk of iatrogenic complications, minimize spread of nosocomial infections, andoverall increase patient comfort.

Middle meningeal artery embolization for chronic subdural hematoma in a young patient with refractory thrombocytopenia secondary to leukemia: more evidence for a paradigm shift? Illustrative case.

Chronic subdural hematoma (CSDH) is one of the most common neurosurgical presentations, with an increasing number now also presenting with concurrent thrombocytopenia. Although middle meningeal artery (MMA) embolization has been considered in elderly patients with high comorbidities, it may permit treatment of CSDH in patients who are at high risk for recurrence or deemed unsuitable for surgical management due to thrombocytopenia. A 35-year-old man who had severe thrombocytopenia due to blast cell crisis with chronic myeloid leukemia developed an atraumatic CSDH. The patient developed severe headaches in the hospital while being treated for febrile neutropenia. He remained neurologically intact. MMA embolization was undertaken due to the morbidity and mortality risks associated with surgery and the high risk of recurrence due to severe thrombocytopenia. At 2 months post-procedure the patient was asymptomatic and there was almost complete resolution of the hematoma. Thrombocytopenia in the presence of a CSDH is becoming increasingly common. This case highlights the particular role of MMA embolization in patients with severe thrombocytopenia where surgery carries high morbidity and increased mortality.

Intraarterial Bevacizumab Administration Through the Middle Meningeal Artery for Chronic Subdural Hematoma

Chronic subdural hematoma has a rising incidence and a high burden of disability and mortality worldwide. The disease process once thought to be from an insidious venous hemorrhage is now believed to be related to chronic inflammation and angiogenesis mediated by vascular endothelial growth factor and other angiogenic factors. Middle meningeal artery embolization is being increasingly used as sole therapy or as a surgical adjunct in the management of chronic subdural hematoma. However, this treatment has risk of migration of embolic material in the presence of unrecognized anastomoses with the retina or other neural tissue. Bevacizumab is a vascular endothelial growth factor‐A receptor antagonist used in the treatment of a number of diseases. We herein report the first case of intraarterial bevacizumab injection in the middle meningeal artery for the treatment of chronic subdural hematoma.

Middle meningeal artery embolisation: The review of a new treatment for chronic subdural hematomas.

This is a literature review aiming to provide an update about the recent findings related to the efficacy of middle meningeal artery embolization (MMAE) in the treatment of chronic subdural hematomas (cSDHs), comparison with conventional therapy and deduction of the current recommendations and indications. The literature is reviewed using a search through the PubMed index using keywords. Studies are then screened, skimmed, and thoroughly read. 32 studies fulfilled the inclusion criteria and are included in the study. Five indications for the application of MMA embolization (MMAE) are deducted from the literature. The usage as a preventive measure after surgical treatment of symptomatic cSDHs in patients with a high risk of recurrence and the usage as a standalone procedure has been the most common reasons for indication of this procedure. Rates of failures for the aforementioned indications have been 6.8% and 3.8%, respectively. The safety of MMAE as a procedure is regarded as a general theme in the literature and can be considered for future applications. Usage of this procedure in clinical trials with more patient segregation and timeframe assessment relative to surgical intervention are recommendations of this literature review.

Embolic Agent Choice in Middle Meningeal Artery Embolization as Primary or Adjunct Treatment for Chronic Subdural Hematoma: A Systematic Review and Meta-analysis.

Middle meningeal artery embolization is an emerging treatment option for chronic subdural hematomas. Our aim was to assess outcomes following middle meningeal artery embolization by different techniques, including in comparison with traditional surgical methods. We searched the literature databases from inception to March 2022. We selected studies reporting outcomes after middle meningeal artery embolization as a primary or adjunctive treatment for chronic subdural hematoma. We analyzed the risk of recurrence of chronic subdural hematoma, reoperation for recurrence or residual hematoma, complications, and radiologic and clinical outcomes using random effects modeling. Additional analyses were performed on the basis of whether middle meningeal artery embolization was used as the primary or adjunct treatment and by embolic agent type. Twenty-two studies were included with 382 patients with middle meningeal artery embolization and 1373 surgical patients. The rate of subdural hematoma recurrence was 4.1%. Fifty (4.2%) patients underwent a reoperation for a recurrent or residual subdural hematoma. Thirty-six (2.6%) experienced postoperative complications. The rates of good radiologic and clinical outcomes were 83.1% and 73.3%, respectively. Middle meningeal artery embolization was significantly associated with decreased odds of subdural hematoma reoperation (OR = 0.48; 95% CI, 23.4-99.1; P = .047) compared with surgery. The lowest rates of subdural hematoma radiologic recurrence, reoperation, and complications were observed among patients receiving embolization with Onyx, whereas good overall clinical outcome occurred most commonly with combined polyvinyl alcohol and coils. A limitation was the retrospective design of studies included. Middle meningeal artery embolization is safe and effective, either as a primary or adjunctive treatment. Treatment using Onyx seems to yield lower rates of recurrence, rescue operation, and complications whereas particles and coils produce good overall clinical outcomes.

Subdural evacuating port system with subdural thrombolysis for the treatment of chronic subdural hematoma in patients older than 80 years.

The subdural evacuating port system (SEPS) is a minimally invasive approach that can be performed under local anesthesia for the treatment of chronic subdural hematoma (CSDH). Subdural thrombolysis has been described as an exhaustive drainage strategy and found to be safe and effective for improving drainage. We aim to analyze the effectiveness of SEPS with subdural thrombolysis in patients older than 80 years. Consecutive patients aged ≥80 years old who presented with symptomatic CSDH and underwent SEPS followed by subdural thrombolysis between January 2014 and February 2021 were retrospectively studied. Outcome measures included complications, mortality, recurrence, and modified Rankin Scale (mRS) scores at discharge and 3 months. In total, 52 patients with CSDH in 57 hemispheres were operated on, with a mean age of 83.9 ± 3.3 years, and 40 (76.9%) patients were men. The preexisting medical comorbidities were observed in 39 patients (75.0%). Postoperative complications occurred in nine patients (17.3%), with two having significant complications (3.8%). The complications observed included pneumonia (11.5%), acute epidural hematoma (3.8%), and ischemic stroke (3.8%). One patient experienced contralateral malignant middle cerebral artery infarction and died of subsequent severe herniation, contributing to a perioperative mortality rate of 1.9%. Discharge and 3 months of favorable outcomes (mRS score 0-3) were achieved in 86.5% and 92.3% of patients, respectively. CSDH recurrence was observed in five patients (9.6%), and repeat SEPS was performed. As an exhaustive drainage strategy, SEPS followed by thrombolysis is safe and effective with excellent outcomes among elderly patients. It is a technically easy and less invasive procedure with similar complications, mortality, and recurrence rates compared with burr-hole drainage in the literature.

Outcomes of Particle versus Liquid Embolic Materials Used in Middle Meningeal Artery Embolization for the Treatment of Chronic Subdural Hematoma

Early evidence suggests that middle meningeal artery (MMA) embolization is an efficacious minimally invasive neuroendovascular technique for the management of chronic subdural hematoma (cSDH). Particle and liquid embolic materials are commonly used to embolize the MMA; however, studies comparing the safety and outcomes between these 2 materials are limited. Patients ≥18 years old who had MMA embolization for cSDH between July 15, 2020 and May 1, 2022 were retrospectively identified from a single-center database. The primary safety, radiation dosage, fluoroscopy time, and radiographic and clinical outcomes were compared between particle and liquid embolization. In a cohort of 116, 48 (41.38%) were treated with liquid embolic material and 68 (58.62%) were treated with particle. The median age of the cohort was 73 years in the particle group and 73.5 years in the liquid embolic group. There was no significant difference in radiation dose or duration among both groups. There was no reported mortality associated with the procedure. One patient experienced nondisabling ischemic stroke in the particle group. Based on imaging follow-up, 3 patients in the particle group and 1 in the liquid embolic group had asymptomatic recurrence. One patient in each group had symptomatic recurrence requiring hematoma evacuation. The index median size of hematoma was 12 mm in the particle group and 11 mm in the liquid embolic group. At approximately 1 month follow-up, the median size of hematoma reduced to 6 mm in both groups. Our series shows that liquid embolic and particle embolization are equally safe and effective among patients undergoing MMA embolization for management of cSDH.

Chronic Subdural Hematoma-Evolution of Etiology and Surgical Treatment.

In this paper, I review the historical changes in the etiological concepts and surgical treatments for chronic subdural hematoma (CSDH) across the world and in Japan. I also examine future problems associated with its surgical procedures and medical costs. CSDH was first reported by Wepfer in 1657 as "delayed apoplexy." In 1857, Virchow described the famous concept of so-called "pachymeningitis hemorrhagica interna." He considered that the etiology of CSDH involved inflammation. In 1914, Trotter described the origin of CSDH as traumatic. Currently, CSDH is considered to arise with a first leak of blood from dural border cells after mild trauma. Inflammatory cells are then drawn to the border cell layer. At this point, new membranes form from activated inflammation; then, the hematoma enlarges, promoted by angiogenic factors and new capillaries. In 1883, Hulke reported successful trepanning of a patient with CSDH. Burr holes and craniotomy for removal of the hematoma were subsequently reported, and new methods were developed over the course of several decades around the world. In Japan, after the first report by Nakada in 1938, many Japanese pioneering figures of neurological surgery have studied CSDH. After Mandai reported the middle meningeal artery embolization in 2000, this method is now considered useful as an initial or second treatment for CSDH. However, the age of patients is increasing, so more minimally invasive surgeries and useful pharmacotherapies are needed. We must also consider the costs for treating CSDH, because of the increasing numbers of surgical cases.

Conservative Treatment of Chronic Subdural Hematoma with Gorei-san.

Most asymptomatic patients with chronic subdural hematoma (CSDH) are followed conservatively but can require surgical treatment if the hematoma expands. We conducted a retrospective evaluation of the effect of Gorei-san on CSDH. This study included patients treated between April 2013 and March 2015. In total, 289 patients were diagnosed with CSDH and 110 patients received conservative management. Finally, 39 patients who met the requirements were registered. We retrospectively examined the age, gender, medical history, hematoma thickness, clarity of sulci below hematomas, and midline shift of the patients. The primary outcome was the median surgery-free interval, and the secondary results were the rate of CSDH shrinkage and surgery avoidance. A comparison of patient characteristics between the Gorei-san (G) and non-Gorei-san (NG) groups found no significant differences in the percentage of men, average ages, past history, thickness of CSDH (15.0 ± 3.1 mm vs. 15.3 ± 2.6 mm, p = 0.801), or midline shift (2.0 ± 2.7 mm vs. 4.0 ± 5.0 mm, p = 0.230). The median surgery-free interval was significantly different between the G and NG groups [n. r. vs. 41 days (95% CI: 5-79), log-rank p = 0.047]. The CSDH avoidance rate was not significantly different between the two groups (70.0% vs. 34.4%, p = 0.071). Additionally, the CSDH shrinkage rate was significantly different between the two groups (60.0% vs. 10.3%, p = 0.004). This retrospective study demonstrated that CSDH treatment with Gorei-san reduces hematoma significantly more than treatment that does not include Gorei-san.

Sequential Middle Meningeal Artery Embolization after Burr Hole Surgery for Recurrent Chronic Subdural Hematoma.

Middle meningeal artery embolization (MMAE) for chronic subdural hematoma (CSDH) is a novel, minimally invasive treatment. The indications and treatment practices for MMAE are variable and remain controversial. This study aimed to evaluate a strategy involving sequential MMAE after burr hole surgery for treating recurrent CSDH. We performed a retrospective analysis of data from consecutive patients who had undergone MMAE using liquid embolic agents within approximately 2 weeks after burr hole surgery for recurrent CSDH from September 2020 to March 2022. We analyzed patient characteristics, procedural details, CSDH recurrence after MMAE, surgical rescue, and complications. Six of the nine patients who underwent MMAE for CSDH recurrence were male, and the median age was 85 (range, 70-94) years. Five of the nine patients were being administered antithrombotic agents. The median duration between the burr hole surgery and MMAE procedure was 10 (range, 3-25) days. Anterior and posterior convexity branches were targeted for embolization using low-concentration N-butyl cyanoacrylate (NBCA), and the abnormal vascular networks with a cotton wool appearance disappeared after embolization in all cases. The NBCA distribution was observed by high-resolution computed tomography during the procedure; in three of nine cases, the NBCA penetrated not only the MMA but also the inner membrane. No recurrence, surgical rescue, or complications were observed in any patient during the median follow-up period of 3 months. As a minimally invasive treatment for recurrent CSDH, sequential MMAE after burr hole surgery may be a safe and effective option for preventing recurrence.

Helical coils augment embolization of the middle meningeal artery for treatment of chronic subdural hematoma: A technical note.

Embolization of the middle meningeal artery (MMA) is a safe and effective adjunct in the treatment of chronic subdural hematoma. While prior authors describe the use of coils to assist embolization by preventing reflux through eloquent collaterals, we de- scribe the use of coils to further open the MMA, allowing the administration of greater amounts of embolisate for a more robust embolization. The objective of this study was to demonstrate that helical coils can safely open the MMA following the administration of polyvinyl alcohol (PVA) particles. This allows for more embolisate to be administered into the MMA for more effective treatment. A retrospective review was conducted at our institution including intraoperative images and postoperative clinical and radiographic follow up. Failure rates using MMA embolization with PVA and helical coil augmentation were compared to failure rates in the literature of MMA embolization with PVA or ethylene vinyl-alcohol copolymer alone. A total of 8 cases were reviewed in which this technique was implemented. There were no immediate complications after treatment. All patients that underwent helical coil embolization following the administration of PVA had increased amount of embolisate delivered into the MMA. All patients at follow up had resolution of the subdural hematoma on outpatient imaging. Helical coil embolization allows for more embolisate administration into the MMA and provides a technical advantage for patients that fail traditional techniques of embolization. Case series are taking place to further test this hypothesis and identify the ideal patient population that may gain maximal yield from this novel technique.