Treatment Of cSDH Research Articles

Risk Factors Associated With Seizure After Treatment of Chronic Subdural Hemorrhage: A Systematic Review and Meta-Analysis.

Chronic subdural hemorrhage (cSDH) is a prevalent neurosurgical pathology, marked by blood collection between the dura mater and the arachnoid membrane. The aim of this systematic review was to provide a comprehensive overview of the risk factors associated with seizures after cSDH treatment. We systematically searched the following databases for studies conducted until September 28, 2023: PubMed, Embase, SCOPUS, Cochrane Central, WOS, and EBSCO. We selected all studies aiming to assess risk factors associated with seizures after treatment of cSDH. Observation studies written in English, Spanish, and Portuguese were included. The quality of studies was assessed using the Newcastle-Ottawa scale for observational studies. A total of 1830 studies were screened after the elimination of duplicates. A total of 18 studies were included, representing 4966 patients. The pooled proportion of seizures after treatment of cSDH is 10% [95% CI 7%, 13%; I2 = 93%]. The risk of seizures was lower in patients undergoing burr hole surgery compared to craniotomy, with an odds ratio of 0.23 (95% CI [0.10, 0.55]; I2 = 0%). Additionally, the risk of seizures in patients receiving prophylactic antiepileptic treatment compared to those without was higher, with an odds ratio of 2.62 (95% CI [0.53, 13.06]; I2 = 66%). Burr-hole treatment after cSDH presents a lower risk of seizures compared with craniotomy, and the use of prophylactic antiepileptic treatment did not conclusively affect seizure outcomes. Standardization in the reporting of outcomes and more comparative studies are needed to enable better recognition of risk factors of seizures after cSDH treatment.

Endovascular treatment of chronic subdural hematoma in a dual-trained neurosurgical unit: Results and proposal of a randomized controlled trial protocol

IntroductionChronic subdural hematoma (cSDH) is a prevalent neurosurgical condition with an increasing incidence due to the rising life expectancy and the widespread use of anticoagulant and antiplatelet therapies. Insights into the inflammatory origins of cSDH led to the exploration of Middle Meningeal Artery (MMA) embolization as a therapeutic strategy. In recent years the endovascular treatment of MMA has gained momentum. Herein we present the initial experience of a dual trained neurovascular unit implementing this therapeutic technique. MethodsThis single-center, prospective pilot study aimed to evaluate the feasibility, safety, and efficacy of MMA embolization in the treatment of cSDH. Following ethical approval and informed consent, demographic, clinical, and radiological data were collected. Patients requiring emergent surgical treatment were excluded. The study focused on assessing clinical outcomes, including the Modified Rankin Score (mRS) and volumetric analysis of cSDH, before and after embolization. ResultsFifteen patients underwent MMA embolization, with a predominance of males (80%) and a mean age of 72.4 years. The most common presenting symptom was headache (53.3%). The average hospital stay was 3.9 days. Various embolization techniques were employed, with DMSO-EVOH being the most frequent. All procedures were successfully conducted without complications. Although not statistically significant, trends suggested better outcomes in patients with homogeneous cSDH on the CT scan, displaying the cotton wool sign on angiography and treated with EVOH-DMSO. ConclusionMMA embolization for cSDH demonstrates promise as a safe and effective treatment, potentially reducing the need for surgical intervention and recurrence rates. This study lays the groundwork for a larger, randomized controlled trial which protocol is herein presented.

Simultaneous resolution of arachnoid cyst and chronic subdural hematoma after middle meningeal artery embolization: illustrative case.

Arachnoid cysts are cerebrospinal fluid-filled spaces that are typically congenital and treated conservatively or with fenestration when symptomatic. Chronic subdural hematomas (cSDHs) can arise in the presence of arachnoid cysts due to fragile leptomeningeal vessels or veins within the cyst wall or cyst lumen, leading to bleeding and subsequent hematoma formation. Middle meningeal artery (MMA) embolization is regularly used for the treatment of cSDH as an alternative to craniotomy and evacuation. Here, the authors present the first known report of the simultaneous resolution of an arachnoid cyst and cSDH following MMA embolization in an adult. A 24-year-old male presented to the emergency department with 1 month of worsening headaches. Imaging revealed the presence of a cSDH and ipsilateral arachnoid cyst. The cSDH was treated with MMA embolization using coils exclusively. Follow-up imaging 4 months after embolization demonstrated simultaneous resolution of both the hematoma and the arachnoid cyst. MMA embolization has been used for the treatment of cSDH. In cases in which the hematoma is related to an arachnoid cyst, MMA embolization can also lead to the concurrent resolution of both pathologies. https://thejns.org/doi/10.3171/CASE24192.

Comparison between the use of subdural and subgaleal drainage in treatment of chronic subdural hematoma

Background and objectivesChronic subdural hematoma (CSDH) is one of the most common pathologies in our daily practice. The standard treatment is the evacuation making a burr-hole and placement of a subdural drainage, which has shown to decrease its recurrence. However, this procedure can entail risks such as parenchymal damage, infection, or the onset of seizures, prompting the consideration of subgaleal drainage as an alternative.Our objective is to compare the use of subdural and subgaleal drainage in a cohort of patients undergoing intervention for CSDH, as well as to analyze the differences in complication rates and recurrence between the two groups. MethodologyA retrospective analytical observational study was conducted, analyzing 152 patients diagnosed with CSDH who underwent intervention at our center from January 2020 to April 2022. Patients in whom drainage was not placed were excluded. In all patients, a burr-hole was performed and the type of drainage was chosen by the neurosurgeon. ResultsOut of the 152 patients, subdural drainage was placed in 80 cases (52.63%), while subgaleal drainage was used in 72 cases (47.37%). There were no significant differences in the recurrence rate (30% in the subdural drainage group vs. 20.83% in the subgaleal drainage group; P = .134) or in the complication rate (7.5% in the subdural drainage group vs. 5.5% in the subgaleal drainage group; P = .749). ConclusionsSubgaleal drainage shows similar clinical outcomes with a recurrence and complication rate comparable to subdural drainage, suggesting it as a safe and effective alternative to subdural drainage in the treatment of CSDH.

Comparación entre el uso de drenaje subdural y subgaleal en tratamiento del hematoma subdural crónico

Background and objetivesChronic subdural hematoma (CSDH) is one of the most common pathologies in our daily practice. The standard treatment is the evacuation making a burr-hole and placement of a subdural drainage, which has shown to decrease its recurrence. However, this procedure can entail risks such as parenchymal damage, infection, or the onset of seizures, prompting the consideration of subgaleal drainage as an alternative.Our objective is to compare the use of subdural and subgaleal drainage in a cohort of patients undergoing intervention for CSDH, as well as to analyze the differences in complication rates and recurrence between the two groups. MethodologyA retrospective analytical observational study was conducted, analyzing 152 patients diagnosed with CSDH who underwent intervention at our center from January 2020 to April 2022. Patients in whom drainage was not placed were excluded. In all patients, a burr-hole was performed and the type of drainage was chosen by the neurosurgeon. ResultsOut of the 152 patients, subdural drainage was placed in 80 cases (52.63%), while subgaleal drainage was used in 72 cases (47.37%). There were no significant differences in the recurrence rate (30% in the subdural drainage group vs. 20.83% in the subgaleal drainage group; P=.134) or in the complication rate (7.5% in the subdural drainage group vs. 5.5% in the subgaleal drainage group; P=.749). ConclusionsSubgaleal drainage shows similar clinical outcomes with a recurrence and complication rate comparable to subdural drainage, suggesting it as a safe and effective alternative to subdural drainage in the treatment of CSDH.

252 Chronic Subdural Hematoma Drainage Under Local Versus General Anesthesia: Systematic Review and Meta-analysis

INTRODUCTION: Chronic subdural hematoma (CSDH) is one of the most encountered conditions seen in neurosurgery. Although mainstay treatment of cSDH has been burr hole drainage, no consensus yet exists on optimal anesthetic technique for surgical treatment between general (GA) and local (LA) anesthesia. METHODS: A search was conducted in MEDLINE (1946 to November 11, 2022), Embase (1974 to November 11, 2022), and PubMed (up to November 11, 2022). We followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines to systematically screen studies. RESULTS: Our literature search identified 521 studies, out of which 20 were included. There were a total of 1750 patients in the LA group and 699 patients in the GA group. Our meta-analysis found that the LA group had significant shorter operative time (mean difference -29.28 minutes, p <0.0001), length of admission (Mean difference -1.58 days, 95% CI = -2.40 to -0.76 days, p = 0.0002), and postoperative complications rate (odds ratio 0.38, 95% CI = 0.25 to 0.59, p < 0.0001) compared to GA. There was no significant difference between the two groups in revision rate (odds ratio 2.71, 95% CI 0.89 to 8.25, p = 0.08) and mortality rate (odds ratio 1.23, 95% CI 0.63 to 2.43, p = 0.55). CONCLUSIONS: In this meta-analysis, LA shows benefits in shorter operative time, shorter admission length, and fewer postoperative complications. This makes local anesthesia a less invasive alternative to general anesthesia especially in elderly patients.

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

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

Chronic Subdural Hematoma Drainage under Local versus General Anesthesia: Systematic Review and Meta-Analysis

BackgroundChronic subdural hematoma (CSDH) is one of the most frequently encountered neurosurgical conditions. Although mainstay treatment of cSDH has been burr hole drainage, no consensus yet exists on optimal anesthetic strategy between general (GA) and local (LA) anesthesia. This systematic review compares post-operative outcomes after CSDH evacuation under LA and GA. MethodsA search was conducted in MEDLINE (1946 to November 2022), Embase (1974 to November 2022), and PubMed (up to November 2022). We followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines to systematically screen studies. ResultsOur literature search identified 629 studies, out of which 12 were included. There were a total of 1035 patients in the LA group and 699 patients in the GA group. Our meta-analysis found that the LA group had significant shorter operative time (mean difference -29.28 minutes, p <0.0001), length of admission (Mean difference -1.58 days, 95% CI = -2.40 to -0.76 days, p = 0.0002), and postoperative complications rate (odds ratio 0.38, 95% CI = 0.25 to 0.59, p < 0.0001) compared to GA. There was no significant difference between the two groups in revision rate (odds ratio 0.77, 95% CI 0.39 to 1.51, p = 0.45) and mortality rate (odds ratio 1.23, 95% CI 0.63 to 2.43, p = 0.55). ConclusionsIn this meta-analysis, LA shows benefits in shorter operative time, shorter admission length, and fewer postoperative complications. This makes local anesthesia a less invasive alternative to general anesthesia, especially in elderly patients.

Featured minimally invasive therapeutic approach for chronic subdural hematoma: Embolization of middle meningeal artery - A narrative review.

Chronic subdural hematoma (c-SDH) is a frequent and serious neurological disease. It develops due to hemorrhage to the subdural space, mainly caused by head trauma. The middle meningeal artery (MMA) plays a critical role in the supply of blood to c-SDH. The decision on the type of treatment for c-SDH depends mainly on clinical and imaging evaluation. In cases in which patients are critically ill, the hematoma must be evacuated immediately. For this purpose, surgery is generally accepted as the mainstay of treatment. Among surgical techniques, twist-drill craniotomy, burr-hole craniotomy, and craniotomy are the three most used. The recurrence rate of c-SDH after surgery is an important problem with a rate of up to 30%. The technical success classification embolization of MMA (EMMA) has emerged as an effective and safe option for the treatment of c-SDH, especially those that recur. EMMA is commonly used as an adjunct to surgery or less frequently alone. The technical success of EMMA has been a promising minimal invasive strategy as an alternative or adjunctive therapy to surgical methods. Polyvinyl alcohol is the most widely used among various embolizing agents, including n-butyl cyanoacrylate, coil, and gelatin sponge. EMMA has been shown to prevent the formation or recurrence of c-SDH by eliminating blood flow to the subdural space. Complication rates are low. The large-scale comparative prospective will ensure efficacy and safety. This article aims to highlight the current information about EMMA in patients with c-SDH.

Comparative outcomes of middle meningeal artery embolization with statins versus embolization alone in the treatment of chronic subdural hematoma: a systematic review and meta-analysis.

Chronic subdural hematoma (cSDH) is common among the elderly, with surgical evacuation as a prevalent treatment, facing recurrence rates up to 30%. Recently, middle meningeal artery embolization (MMAE) has emerged as a promising approach, offering reduced treatment failures and recurrence rates. Additionally, statins, known for their anti-inflammatory properties, have been considered as a potential adjunctive or sole treatment for cSDH. However, the combination of MMAE with statins remains understudied. This systematic review and meta-analysis aims to evaluate the comparative outcomes of MMAE with statins versus MMAE alone in the treatment of cSDH. A comprehensive systematic search of the PubMed, Web of Science, and SCOPUS databases was conducted. Inclusion criteria were: studies published in English between the dates of inception of each database and August 2023, studies comparing the treatment of cSDH with either MMAE + statin or MMAE alone were included. Main outcome measures were complete resolution of the hematoma at follow-up and the recurrence rates. Two studies comprising 715 patients were included; 408 patients underwent MMAE + statin; and 307 underwent MMAE alone. MMAE + statin was not significantly superior to MMAE alone in achieving complete resolution of the hematoma at follow-up (RR: 0.99; CI: 0.91 to 1.07, P = 0.84), nor was it a significant difference in rates of recurrence (RR: 1.35; CI: 0.83 to 2.17, P = 0.21) between the two groups. MMAE + statin did not demonstrate significant superiority over MMAE alone for achieving complete resolution and decreasing the recurrence rates in cSDH patients. Further research with larger, randomized studies may be required to fully elucidate the potential synergistic effects of MMAE and statins in this patient population.

Incidence, therapy, and outcome in the management of chronic subdural hematoma in Switzerland: a population-based multicenter cohort study.

Chronic subdural hematoma (cSDH) is a disease affecting mainly elderly individuals. The reported incidence ranges from 2.0/100,000 to 58 per 100,000 person-years when only considering patients who are over 70 years old, with an overall incidence of 8.2-14.0 per 100,000 persons. Due to an estimated doubling of the population above 65 years old between 2000 and 2030, cSDH will become an even more significant concern. To gain an overview of cSDH hospital admission rates, treatment, and outcome, we performed this multicenter national cohort study of patients requiring surgical treatment of cSDH. A multicenter cohort study included patients treated in 2013 in a Swiss center accredited for residency. Demographics, medical history, symptoms, and medication were recorded. Imaging at admission was evaluated, and therapy was divided into burr hole craniostomy (BHC), twist drill craniostomy (TDC), and craniotomy. Patients' outcomes were dichotomized into good (mRS, 0-3) and poor (mRS, 4-6) outcomes. A two-sided t-test for unpaired variables was performed, while a chi-square test was performed for categorical variables, and a p-value of <0.05 was considered to be statistically significant. A total of 663 patients were included. The median age was 76 years, and the overall incidence rate was 8.2/100,000. With age, the incidence rate increased to 64.2/100,000 in patients aged 80-89 years. The most prevalent symptoms were gait disturbance in 362 (58.6%) of patients, headache in 286 (46.4%), and focal neurological deficits in 252 (40.7%). CSDH distribution was unilateral in 478 (72.1%) patients, while 185 presented a bilateral hematoma with no difference in the outcome. BHC was the most performed procedure for 758 (97.3%) evacuations. CSDH recurrence was noted in 104 patients (20.1%). A good outcome was seen in almost 81% of patients. Factors associated with poor outcomes were age, GCS and mRS on admission, and the occurrence of multiple deficits present at the diagnosis of the cSDH. As the first multicenter national cohort-based study analyzing the disease burden of cSDH, our study reveals that the hospital admission rate of cSDH was 8.2/100,000, while with age, it rose to 64.2/100,000. A good outcome was seen in 81% of patients, who maintained the same quality of life as before the surgery. However, the mortality rate was 4%.

Post-operative Treatment Chronic Subdural Hematoma with or without Dexamethasone: a Systematic Review

Abstract Introduction: Discovering If the post-operative patient is given dexamethasone or without dexamethasone, it can cause recurrence of Chronic Subdural Hematoma patients. This systematic review aims to summarize the research on the link between dexamethasone and recurrent chronic subdural hematoma. Methods: We present systematic reviews reported according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) and adhere to a structured review protocol. We searched PubMed, ScienceDirect, and British Medical Journal databases using the following search strategy from inception to March 2023. Results: Four studies were included for further analysis. CSDH can be treated as medical, surgical, or both medical surgeries. Medical treatment for post-traumatic and post-operative prophylaxis of seizures and for preventing edema and ischemia. Anticonvulsant agents can be cut off after a few weeks if post-operative seizures do not appear at all. Surgery has been shown to be most effective in the treatment of cSDH. The evacuation of subdural collections forms the basis of the surgery in cSDH. After treatment, residual subdural fluid collections are standard. The most critical and dangerous complications of surgical treatment of acute post-operative bleeding. Discussion: Chronic subdural hematoma is an event of head bleeding that occurs for more than three weeks. It can be examined using CT (Computed Tomography). Often occurs in parents. The operation was carried out using the burr-hole method, and post-operative treatment can be given using dexamethasone. Recurrent bleeding may occur in patients with chronic subdural hematoma.

Middle Meningeal Artery Embolization for Chronic Subdural Hematoma: A Review of Established and Emerging Embolic Agents

Middle meningeal artery embolization is an increasingly common procedure involved in the treatment of chronic subdural hematoma (cSDH) that can be an adjuvant intervention or an alternative to traditional medical or surgical therapies. Our review aims to summarize the mechanism, properties, and available clinical data for current and investigative embolic agents used for the treatment of cSDH. Pubmed, Scopus, and clinicaltrials.gov were searched for relevant studies and ongoing trials that examine middle meningeal artery embolization for cSDH. Particle agents, liquid embolic agents, and coil embolization are the common classes of embolic materials used in clinical practice and in ongoing trials. These embolic agents are not only mechanical occlusive materials; they have unique properties that address the angiogenic and proinflammatory mechanisms that propagate and sustain cSDH. Particle agents, such as polyvinyl alcohol and Embosphere (tris‐acryl gelatin microspheres) have been the most commonly used embolic agents given the long‐term evidence base regarding efficacy and established safety record. Liquid embolic agents such as cyanoacrylate glues and copolymer agents such as Onyx, Squid, and PHIL are increasingly common in clinical settings due to improved visualization on imaging, durable embolization, and better control of distal embolization. Coil embolization is used in conjunction with other embolic agents or as monotherapy in the setting of dangerous middle meningeal artery anastomoses. There are several ongoing randomized clinical trials and prospective cohort studies that will clarify the safety, efficacy, and use cases of particle agents, liquid embolic agents, and coil embolization for the treatment of cSDH.

Efficacy of the Non-Surgical Treatment of Chronic Subdural Hematoma: A Systematic Review

Background Chronic subdural hematoma (CSDH) is one of the most common neurological diseases. Surgical treatment is the gold standard treatment. However, the hematoma recurs in up to 25% of cases. In addition, many complications may occur after surgery. Despite the fact that conservative treatment for CSDH has grown in popularity, no medicine currently has level 1 evidence to back it up. Objective To figure out the efficacy of the non-surgical treatment of CSDH and to highlight its role in mildly symptomatic or asymptomatic patients. Patients and Methods The following electronic databases were searched for studies from 2000 to 2020: PubMed, Google Scholar, EMBASE, and Science Direct, using appropriate combinations of the following Keywords: chronic subdural hematoma, hemorrhage, CSDH, bleeding, non-surgical treatment, conservative management or treatment, alternative management or treatment, dexamethasone, steroids, corticosteroid, pharmacological treatment. Results Fifteen studies met our selection criteria. A total of 616 patients received medical treatment for CSDH. Their mean age was 70.49 years, including 468 males (76%) and 148 females (24%). Improvement of the presenting symptoms occurred in 477 patients (77.44%), and 139 patients (22.56%) required surgical intervention. Conclusion The results of the previous studies suggested that medical treatment in selected patients was a valid option as a primary treatment and as an adjuvant therapy with surgical evacuation for CSDH. Further randomized controlled studies with larger patient cohorts are needed to determine the true value of each drug in the conservative treatment of CSDH.

P.122 Chronic subdural hematoma drainage under local vs. general anesthesia: systematic review and meta-analysis

Background: Chronic subdural hematoma (CSDH) is one of the most encountered conditions seen in neurosurgery. Although mainstay treatment of cSDH has been burr hole drainage, no consensus yet exists on optimal anesthesic technique for surgical treatment between general (GA) and local (LA) anesthesia. Methods: A search was conducted in MEDLINE (1946 to November 11, 2022), Embase (1974 to November 11, 2022), and PubMed (up to November 11, 2022). We followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines to systematically screen studies. Results: Our literature search identified 521 studies, out of which 20 were included. There were a total of 1750 patients who underwent CSDH drainage under LA. The weighted mean age was 71.0 years, and 27.1% were female. Postoperative complication rate was significantly lower in the LA group (odds ratio 0.44, p = 0.004). The mean operative time (mean difference -29.28 minutes, p &lt;0.0001) and length of admission (mean difference -1.58 days, p = 0.0002) were significantly shorter in the LA group. Conclusions: In this meta-analysis, LA shows benefits in shorter operative time, shorter admission length, and fewer postoperative complications. This makes local anesthesia a less invasive alternative to general anesthesia especially in elderly patients.

Cost Comparison for Open Surgery versus Middle Meningeal Artery Embolization in Patients with Chronic Subdural Hematomas: A Propensity Score-Matched Analysis.

Chronic subdural hematoma (cSDH) can be treated with conventional surgery or middle meningeal artery embolization (MMAE). The cost profiles of open surgery versus MMAE have never been studied. Therefore, we sought to compare the costs of surgical and MMAE treatment of cSDH. Patients treated with open surgery (2006-2019) and MMAE (2018-2020) were identified from the institutional database. Propensity score matching analysis was used to assemble a balanced group of subjects. Detailed hospitalization costs in each group were collected and compared. A total of 341 conventionally treated and 52 MMAE cases were identified. After propensity score matching, 33 patients were included in each group, for a total of 66 patients for analysis. Direct procedural cost was significantly greater in the MMAE group compared with the open surgery group ($38,255 ± $11,859 vs. $11,206 ± $7888; P < 0.001). Medication cost also was greater in the MMAE group ($6888 ± $6525 vs. $4291 ± $3547; P= 0.048). No significant difference was found in costs for intensive care unit care, pharmacy, therapy, laboratory values, and the emergency department. Imaging costs and other miscellaneous costs (e.g., wound care, preoperative, and postanesthesia care unit) were greater in the open surgery group (P < 0.05). Total hospitalization cost was not significantly different between the 2 groups ($60,598 ± 61,315 vs. $71,569 ± $37,813 for open surgery and MMAE respectively, P= 0.385). No significant differences in number of follow ups or total costs for follow up were found (P > 0.05). Open surgery and MMAE offer an overall equivalent cost-profile for cSDH treatment when matching for potential cost confounders. Direct procedural costs are greater in MMAE; however, total hospitalization costs and follow up costs are not significantly different.

Multi-Technique Management of Chronic Subdural Hematoma in a Single Patient: A Case Report

Background: Chronic Subdural Hematoma (cSDH) is one of the most everyday neurosurgical conditions. Unfortunately, there is no defined gold standard technique in managing cSDH, as studies show mixed results with no consensus on the superiority of a particular method. This lack of uniformity in the treatment of cSDH makes the management choice dependent on the clinical symptomatology, surgeon’s preference, and recurrence after a prior intervention.&#x0D; Different management approaches are available, ranging from novel medical therapy, e.g., steroids, etizolam, tranexamic acid, angiotensin-converting enzymes inhibitors (ACEIs), to minimally invasive techniques, e.g., endovascular middle meningeal artery (MMA) embolization and endoscopic treatment, to more invasive surgical approaches, e.g., twist drill craniostomy, burr hole craniostomy, and craniotomy.&#x0D; A component network meta-analysis by Jack et al. showed a 10.8% recurrence rate (95% CI 10.2-11.5) across 418 studies involving different management techniques. The use of a post-operative drain and MMA embolization reduced recurrence, while the risk of morbidity was equivalent across surgical treatments.&#x0D; We aim to present the multi-technique management approaches required to achieve clinical and radiological resolution in a cSDH patient.&#x0D; The Case: We report the clinical course and management of a 47-year-old male with no history of trauma who presented with sudden onset of severe headaches and brain computed tomography scan finding of bilateral cSDH. He required multiple treatment techniques, starting with bilateral twist drill craniostomies and Jackson-Pratt drain insertion with the resolution of the right collection and recurrence of the left collection. He further required the placement of two left burr hole craniostomies for drainage. However, the collection recurred. He then proceeded to have a left middle meningeal artery embolization and a left craniotomy before a clinical and radiological resolution was achieved.&#x0D; Conclusion: The management of cSDH is still an art and not a cookbook. Familiarity of clinicians with multiple techniques and selection based on clinical judgment is essential for improved outcomes. Appropriate patient selection for the right technique will depend on accumulating data from clinical practice and its analysis.

Modified Valsalva maneuver after burr-hole drainage of chronic subdural hematomas: A single-center cohort study.

Previous studies on the management of chronic subdural hematoma (cSDH) mainly focused on the risk of postoperative recurrence and measures to prevent it. In this study, we propose the use of a non-invasive postoperative treatment method, the modified Valsalva maneuver (MVM), as a means of reducing the recurrence of cSDH. This study aims to clarify the effects of MVM on functional outcomes and recurrence rates. A prospective study was conducted at the Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology from November 2016 to December 2020. The study included 285 adult patients who underwent burr-hole drainage for the treatment of cSDH and received subdural drains. These patients were divided into two groups: the MVM group (n = 117) and the control group (n = 98). In the MVM group, patients received treatment with a customized MVM device for at least 10 times per hour, 12 h per day. The study's primary endpoint was the recurrence rate of SDH, while functional outcomes and morbidity 3 months after surgery were the secondary outcomes. In the current study, 9 out of 117 patients (7.7%) in the MVM group experienced a recurrence of SDH, while 19 out of 98 patients (19.4%, p < 0.05) in the HC group experienced a recurrence of SDH. Additionally, the infection rate of diseases such as pneumonia (1.7%) was significantly lower in the MVM group compared to the HC group (9.2%, p < 0.001, odds ratio (OR = 0.1). After 3 months of the surgery, 109 out of 117 patients (93.2%) in the MVM group achieved a favorable prognosis, compared to 80 out of 98 patients (81.6%) in the HC group (p = 0.008, with an OR of 2.9). Additionally, infection rate (with an OR of 0.2) and age (with an OR of 0.9) are independent predictors of a favorable prognosis at the follow-up stage. The use of MVM in the postoperative management of cSDHs has been shown to be safe and effective, resulting in reduced rates of cSDH recurrence and infection following burr-hole drainage. These findings suggest that MVM treatment may lead to a more favorable prognosis at the follow-up stage.

Membrane Tucking Technique using Ligature Clips with Intermembranous Placement of Oxidized Regenerated Cellulose in Multilayered Chronic Subdural Hematoma: Description of Novel Technique and our Initial Experience.

Chronic subdural hematoma (cSDH) is an encapsulated collection of blood and blood degradation products between dural border cell layers, the pathophysiology of formation and expansion of which is still debatable. It is usually seen in the elderly population, and surgical evacuation is the primary mode of treatment. The main hurdle in the treatment of cSDH is postoperative recurrences and the need for repeat operations. A few authors have classified cSDH into homogenous, gradation, separated, trabecular, and laminar types based on the internal architecture of hematoma and proposed that separated, laminar, and gradation types of cSDH have a high propensity of recurrence after surgery. A similar problem was described with multi-layered or multi-membrane cSDH. Based on the most accepted theory of formation and expansion of cSDH that suggests a complex and vicious process of membrane formation, chronic inflammation, neoangiogenesis, rebleeding from fragile capillaries, and increased fibrinolysis, we propose our theory of intermembranous placement of oxidized regenerated cellulose and membrane tucking using ligature clips to prevent recurrence in multi membranous cSDH by ceasing the ongoing cascade in hematoma's internal milieu and thus preventing recurrence and reoperation in such cases. This is the first in the world literature report describing such a technique for treating multi-layered cSDH and in our series, the reoperation and postoperative recurrence rates were 0% in patients treated by the described technique.

Onyx Versus Particles for Middle Meningeal Artery Embolization in Chronic Subdural Hematoma.

Middle meningeal artery (MMA) embolization has recently emerged as a treatment option for chronic subdural hematoma (cSDH). It is considered a simple and potentially safe endovascular procedure. To compare between 2 different embolic agents; onyx (ethylene vinyl alcohol) and emboparticles (polyvinyl alcohol particles-PVA) for endovascular treatment of cSDH. A retrospective analysis of all patients who underwent MMA embolization for cSDH treatment in 2 comprehensive centers between August 2018 and December 2021. Primary outcomes were failure of embolization and need for rescue surgical evacuation. Among 97 MMA embolizations, 49 (50.5%) received onyx and 48 (49.5%) received PVA. The presence of acute or subacute on cSDH was higher in the PVA group 11/49 (22.5%) vs 30/48 (62.5%), respectively, P < .001. There were no significant differences between both groups regarding failure of embolization 6/49 (12.2%) vs 12/48 (25.0%), respectively, P = .112, and need of unplanned rescue surgical evacuation 5/49 (10.2%) vs 8/48 (16.7%), respectively, P = .354. Hematoma thickness at late follow-up was significantly smaller in the PVA group 7.8 mm vs 4.6 mm, respectively; P = .017. Both onyx and PVA as embolic agents for cSDH can be used safely and have comparable clinical and surgical outcomes.