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Walid K. Salah, Cordell Baker, Jonathan P. Scoville, Joshua C. Hunsaker, Christopher S. Ogilvy, Justin M. Moore, Howard A. Riina, , Alejandro M. Spiotta, Brian T. Jankowitz, et al.
Published: 13 March 2023
Interventional Neuroradiology;

Background: By 2030, nonacute subdural hematomas (NASHs) will likely be the most common cranial neurosurgery pathology. Treatment with surgical evacuation may be necessary, but the recurrence rate after surgery is as high as 30%. Minimally invasive middle meningeal artery embolization (MMAE) during the perioperative period has been posited as an adjunctive treatment to decrease the potential for recurrence after surgical evacuation. We evaluated the safety and efficacy of concurrent MMAE in a multi-institutional cohort. Methods: Data from 145 patients (median age 73 years) with NASH who underwent surgical evacuation and MMAE in the perioperative period were retrospectively collected from 15 institutions. The primary outcome was the rate of recurrence requiring repeat surgical intervention. We collected clinical, treatment, and radiographic data at initial presentation, after evacuation, and at 90-day follow-up. Outcomes data were also collected. Results: Preoperatively, the median hematoma width was 18 mm, and subdural membranes were present on imaging in 87.3% of patients. At 90-day follow-up, median NASH width was 6 mm, and 51.4% of patients had at least a 50% decrease of NASH size on imaging. Eight percent of treated NASHs had recurrence that required additional surgical intervention. Of patients with a modified Rankin Scale score at last follow-up, 87.2% had the same or improved mRS score. The total all-cause mortality was 6.0%. Conclusion: This study provides evidence from a multi-institutional cohort that performing MMAE in the perioperative period as an adjunct to surgical evacuation is a safe and effective means to reduce recurrence in patients with NASHs.
Hıdır Özer, Ömer Faruk Şahin
Published: 3 January 2023
Middle Black Sea Journal of Health Science;

Aim: To demonstrate the effectiveness, possible complications, and difference of Burr-hole craniostomy surgical technique applied to patients diagnosed with chronic subdural hematoma from other surgical techniques. Material and Methods: The surgical techniques and postoperative clinical and radiological details of 36 patients who were operated on with the diagnosis of chronic subdural hematoma in the Neurosurgery Clinic of Ordu University Training and Research Hospital between 01.01.2013 and 15.08.2022 were retrospectively analyzed. Twenty-eight (77.7%) of the cases were male and 8 (22.3%) were female. The mean age was 70, with an age range of 54-87. Ten of the cases had a GCS of 15 (28%), 20 had a GCS of 13-14 (56%), and 6 had a GCS of 8-12. The most prominent complaints of the patients were headache and confusion. While 22 patients (61.1%) had a history of head trauma, 14 patients (38.9%) had no history of trauma. There was a history of anticoagulant or antiaggregant drug use in 9 patients (25%). In all patients in the post-op period, control brain CT was taken within the first 24 hours and compared with the pre-op CT. Again, at the end of post-op 1st, 2nd week and 1st month, control brain CT was taken for all patients and GCS was compared with pre-op scores. After determining the post-op complications, the treatment and results of these complications were examined. Results: In all patients in the post-op period, control brain CT was taken within the first 24 hours and compared with the pre-op CT. Again, at the end of post-op 1st, 2nd week and 1st month, control brain CT was taken for all patients and GCS was compared with pre-op scores. Craniotomy + membranectomy was performed in 6 patients because of residual bleeding in the post-op period and no improvement in their neurological status. One of the patients who were operated on by craniotomy died due to sepsis in the later period. One patient who was operated on with Burr-Hole developed motor dysphasia in the post-op period, and intraparenchymal hemorrhage was detected in the post-op tomography of this patient. This patient's dysphasia resolved at the end of the post-op 1 month. Although pneumocephaly developed in the post-op period in 9 patients who underwent burr-hole craniostomy, they did not require surgical treatment and were observed to be spontaneously resorbed. In addition, wound site infection developed in the post-op period in 4 patients who underwent Burr-hole craniostmia. Appropriate antibiotic therapy was given to these patients. At the end of the first week, radiological examination of 18 patients with CT showed no residual hematoma or recurrent hematoma. The radiological improvement of 10 patients was completed at the end of the 1st month and the radiological recovery of 7 patients was completed at the end of the 3rd month. Post-op clinical and radiological results of patients who underwent burr-hole craniostomy were significantly better than pre-op clinical and radiological results, and the recurrence rate was low, consistent with the literature. Conclusion: Although the drainage of chronic subdural hematoma with bur-hole craniostomy has a higher recurrence rate compared to the craniotomy method, it has a lower complication rate and is a more easily applicable surgical technique. In our study, some important points about patients who underwent burrhole craniostomy for cSDH evacuation were highlighted. It was observed that our patients who underwent burrhole craniostomy had higher reoperation rates compared to our patients who underwent craniotomy. We think that the presence of residual hematoma in the controls performed with CT in the post-op period should not be the sole criterion for re-operation. We think that CT controls are sufficient if there is improvement in the neurological status of the patient and a better GCS score in the post-op follow-up.
Guangwen Xia, Weitao Zhang, Jing Xiao, Lin Shi, Yiming Zhang, Hang Xue
Published: 12 July 2022
Frontiers in Neurology, Volume 13;

Chronic subdural hematoma, a common neurosurgical disease, is mostly caused by craniocerebral trauma. Chronic subdural hematoma caused by acute myeloblastic leukemia is rarely reported, and its pathogenesis and strategies for clinical treatment remain controversial. Here, we report a rare case of chronic subdural hematoma caused by acute myeloblastic leukemia. The patient's condition deteriorated quickly after admission, and emergency trepanation and drainage of the chronic subdural hematoma was performed, followed by oral administration of atorvastatin. The platelet levels continued to decrease during neurosurgical treatment. Bone marrow cytology, flow cytology, and karyotype analysis suggested acute myelocytic leukemia (AML). Then, the patient was transferred to the hematology department for chemotherapy treatment, during which there was no recurrence of hematoma. Chronic subdural hematoma caused by acute myeloblastic leukemia is a very rare disease. Surgery should be performed when the intracranial hematoma is more than 10 mm thick and the midline structures are displaced by more than 5 mm, and postoperative treatment should be supplemented with atorvastatin to prevent recurrence. Chemotherapy should be given promptly to treat leukemia after stabilization of neurological conditions.
, Muhittin Belirgen
Journal of Neurosciences in Rural Practice, Volume 13, pp 576-577;

Craniotomy is a common surgery used to expose the brain by removing a part of the bone from the skull. During surgery, bone flaps can be fixed by using variety of materials that can migrate in the long term. A 7-year-old boy presented several years after the craniotomy and subdural peritoneal (SP) shunt surgeries. It was decided to remove the shunt catheter, and during the diagnostic tests, we saw that a loosened titanium screw has migrated along the SP shunt catheter from the skull into the abdominal wall. To the best of our knowledge, this is the first case in the reported electronic literature for a pediatric patient with a subcutaneous migration of a screw along the shunt catheter.
Sergio Paolini, , Cristina Mancarella, Giovanni Cardarelli, Marco Ciavarro, Augusto Di Castelnuovo, Licia Iacoviello, Giuseppe Minniti
Neurosurgical Review, Volume 45, pp 2983-2991;

The publisher has not yet granted permission to display this abstract.
Published: 28 February 2022
Journal of Clinical Medicine, Volume 11;

Objective: To investigate the effects of minimally invasive surgery (MIS) using a novel YL-1 puncture needle and summarize the risk factors of recurrence in chronic subdural hematoma (CSDH). Methods: We performed a retrospective analysis in 516 hospitalized patients with CSDH from January 2013 to December 2018 in Northern Jiangsu People’s Hospital. Patients’ gender, age, history of trauma, use of anticoagulants, history of disturbed liver or renal function, history of heart disease, history of malignant tumor, history of diabetes, hemodialysis, coagulopathy, alcoholism, imaging indicators, and postoperative application of urokinase or atorvastatin were recorded. Recurrence is defined by imaging examination with or without clinical presentation three months after discharge. Results: In total, 483 patients (93.60%) benefited from MIS by YL-1 needle. Gender, age, history of head trauma, history of disturbed liver function, history of heart disease, history of malignant tumor, history of diabetes, history of hemodialysis, coagulopathy, alcoholism, hematoma location, hematoma densities, septum formation, maximum thickness, encephalatrophy, and use of atorvastatin and urokinase were shown to be non-significantly associated with postoperative recurrence (p > 0.05). The use of anticoagulants was significantly associated with postoperative recurrence (p > 0. 05). Logistic analysis showed that the use of anticoagulants is an independent factor predicting postoperative recurrence (p > 0. 05). Conclusions: The novel YL-1 puncture needle turned out to be a safe and effective minimally invasive surgery, and the use of anticoagulants is an independent risk factor predicting postoperative recurrence in CSDH, which can provide MIS and early therapeutic strategies for neurosurgeons.
Jianhong Deng, Fangyu Wang, Haojie Wang, Mingpei Zhao, Guorong Chen, Huangcheng Shangguan, Lianghong Yu, Changzhen Jiang, Wenhua Fang, Peisen Yao, et al.
Published: 11 January 2022
Frontiers in Neurology, Volume 12;

Objective: Neuroendoscopic treatment is an alternative therapeutic strategy for the treatment of septate chronic subdural hematoma (sCSDH). However, the safety and efficacy of this strategy remain controversial. We compared the clinical outcomes of neuroendoscopic treatment with those of standard (large bone flap) craniotomy for sCSDH reported in our center. Furthermore, the safety and efficacy of the neuroendoscopic treatment procedure for sCSDH were evaluated.Methods: We retrospectively collected the clinical data of 43 patients (37 men and six women) with sCSDH who underwent either neuroendoscopic treatment or standard (large bone flap) craniotomy, such as sex, age, smoking, drinking, medical history, use of antiplatelet drugs, postoperative complications, sCSDH recurrence, length of hospital stay, and postoperative hospital stay. We recorded the surgical procedures and the neurological function recovery prior to surgery and 6 months following the surgical treatment.Results: The enrolled patients were categorized into neuroendoscopic treatment (n = 23) and standard (large bone flap) craniotomy (n = 20) groups. There were no differences in sex, age, smoking, drinking, medical history, antiplatelet drug use, postoperative complications, and sCSDH recurrence between the two groups (p > 0.05). However, the patients in neuroendoscopic treatment group had a shorter length of total hospital stay and postoperative hospital stay as compared with the standard craniotomy group (total hospital stay: 5.26 ± 1.89 vs. 8.15 ± 1.04 days, p < 0.001; postoperative hospital stay: 4.47 ± 1.95 vs. 7.96 ± 0.97 days, p < 0.001). The imaging and Modified Rankin Scale at the 6-month follow-up were satisfactory, and no sCSDH recurrence was reported in the two groups.Conclusions: The findings of this study indicate that neuroendoscopic treatment is safe and effective for sCSDH; it is minimally invasive and could be clinically utilized.
Harnarayan Singh, Rana Patir, Sandeep Vaishya, Rahul Miglani, Anurag Gupta, Amandeep Kaur
Published: 5 January 2022
Surgical Neurology International, Volume 13;

Background: Chronic subdural hematoma (cSDH) is a common entity in the elderly. Homogeneous or well-liquefied CSDH has a standard line of treatment through burr hole and irrigation. However, the management of septated chronic subdural hematoma (sCSDH) with multiple membranes does not have a well-defined surgical approach. The neomembranes forming septations prevent evacuation of clots through burr holes, and the small remaining loculi with clots will enlarge overtime to cause recurrence. Methods: Patients with sCSDH were operated through a minicraniotomy (2.5 cm × 2.5 cm) using rigid endoscopes for visualization of the subdural space. Using endoscope, the entire subdural space can be visualized. The neomembranes are removed with standard neurosurgical microinstruments. The entire cavity is irrigated under vision to remove all clots and ensures hemostasis. Results: Eighty-three endoscope-assisted evacuations were done in 68 patients from January 2016 to April 2020. Fifty (73.5%) patients had unilateral and 18 (26.5%) had bilateral subdural. Only 1 patient (1.47%) had a clinically significant recollection of subdural bleeding 1 month after the procedure. Over a mean follow-up period of 25.3 months (range 1–53 months), rest of patients did not show any recollection. Conclusion: Endoscopic evacuation of sCSDH is a safe and effective method and can be used to improve clot evacuation, and remove neomembranes under direct vision to reduce the rates of recollection. This method also obviates the need for larger craniotomies to remove membranes.
, Renato Gondar, Karl Schaller,
Published: 2 November 2021
Journal: Brain and Spine
Brain and Spine, Volume 1;

The publisher has not yet granted permission to display this abstract.
Liang Yang, Nan Li, Lijun Yang, Dong Wang, Shuke Qiang,
Journal of Molecular Neuroscience, Volume 72, pp 565-573;

The publisher has not yet granted permission to display this abstract.
, Alexis Gutierrez, Rachel Blue, Dmitriy Petrov
Current Neurology and Neuroscience Reports, Volume 20, pp 1-11;

The publisher has not yet granted permission to display this abstract.
Pınar Aydin Öztürk, Ünal Öztürk, Yusuf Tamam
Published: 25 September 2020
Dicle Tıp Dergisi, Volume 47, pp 735-742;

Amaç: Kronik subdural hematom (Kr.SDH) sık görülen intrakranial bir patoloji olup reversibl demans nedenlerindendir. Daha çok ileri yaş grubun hastalığı olduğundan komorbidite sıklığı oldukça fazladır. Bu nedenle cerrahi olarak kolay yönetilebileceği düşünülse de benign bir antite olmaktan uzaktır. Çalışmamızda Glasgow outcome skalası ve mini mental durum testi ile Kr.SDH’un son durum ve bilişsel fonksiyonlara etkisi araştırılmak istenmiştir. Yöntemler: Kr.SDH nedeniyle takip edilen hastaların demografik ve etyolojik verileri, görüntüleme bulguları, son durum ve mini mental durum testi bulguları değerlendirmeye alınmıştır. Bulgular: Çalışmamızda yaş ortalaması 71.6 (46-88), erkek/kadın oranı; 4:1 olarak tespit edilmiştir. Hastaların %67.1’inde travma öyküsü, %71.6’sında en az bir komorbidite olduğu görülmüştür. Hastaların %64.2’sine cerrahi uygulanmış, cerrahi gerektiren hastaların yaş ortalamasının daha düşük, komorbiditelerinin daha az, travma sonrası cerrahi sürelerinin daha uzun, MMDT puanlarının daha yüksek olduğu görülmüştür. MMDT puanına göre demans grubunun yaşının ileri olduğu, komorbiditelerinin fazla olduğu ve modifiye Glasgow outcome skalalarının düşük olduğu saptandı. Sonuç: Kr.SDH’da demans, patogenezi tam olarak açıklanmayan ancak erken dönemde hematom drenaj ile reversibl olabilen bir bulgudur.
James Feghali, ,
Published: 25 June 2020
World Neurosurgery, Volume 141, pp 339-345;

Chronic subdural hematoma (CSDH) is a complex disease with an overall incidence of 1.7-20.6 per 100,000 persons per year and is more commonly encountered in the elderly population. The pathophysiologic cycle of CSDH formation and expansion involves traumatic and inflammatory components that promote the formation of membranes with permeable neo-vessels. Many drugs targeting different elements of this cycle are being actively investigated as potential therapeutic agents in CSDH. Burr hole craniostomy appears to be the most commonly used procedure for surgical evacuation, and outcomes are generally favorable. Recurrence can occur in 10-20% of patients and is associated with several clinical and radiographic predictors. Middle meningeal artery embolization represents one of the latest additions to the therapeutic arsenal of cerebrovascular specialists in treating CSDH and is being critically evaluated in numerous ongoing clinical trials.
Published: 1 November 2019
Journal: Cureus
The operative management of subacute subdural hematomas (sSDHs) and chronic subdural hematomas (cSDHs) in the elderly is complicated by age itself, multiple medical comorbidities, and anticoagulant and antiplatelet medications; therefore, the search for less invasive, yet more effective, treatment techniques has become a goal. Here, we present the use of a repurposed ventriculostomy catheter in the minimally invasive drainage of a mixed sSDH with the residual solid clot component subsequently liquefied with local alteplase (tPA) administration in an elderly female producing effective hematoma and symptom resolution.
, Sara Kierońska, Paweł Słoniewski, Jarosław Dzierżanowski
Published: 1 January 2019
Introduction Standard craniotomy (SC) and burr hole craniostomy (BHC) are regarded as the standard approaches to chronic subdural haematoma (CSDH). Bedside twist drill craniostomy (TDC), performed at the patient’s bedside, was introduced as an alternative to the standard methods. However,...
Shashank Sah, Divyant Rawal
Published: 21 August 2018
Indian Journal of Neurotrauma, Volume 15, pp 057-061;

Background Burr hole drainage (BHD) is the most popular technique for surgical management of chronic subdural hematoma (CSDH) and is able to successfully address the problem in majority of patients. However, in a select few cases, the formation of subdural membrane necessitates a wider surgical approach to relieve the compressed cerebral parenchyma. We evaluated the need for craniotomy and associated issues in management of CSDH in a consecutive series of 114 patients. Material and Method Data of 114 patients, who underwent surgical management of CSDH in our neurosurgical unit were analyzed. We specifically looked for the cases requiring craniotomy, it's indication and surgical outcome. Results Craniotomy was required in 12 patients (8.6%)—as primary procedure in 8 patients and as add-on secondary procedure in 4 patients. Clinical outcome was good. Mild subdural bleed, not requiring any surgical intervention, was observed in two patients as postoperative complication. There was no mortality. Conclusion In the presence of thick subdural membranes, BHD alone may not help relieve the cerebral compression. Wider surgical approach in form of craniotomy and membranectomy is the answer in such situations and can be safely performed with low complications. Good quality computed tomography and magnetic resonance imaging are essential in preoperative identification of membrane and appropriate surgical planning.
, , Clemens M.F. Dirven, Wilco C. Peul, Fop van Kooten, Korné Jellema, Niels A. van der Gaag, Ishita P. Miah, , Heleen M. Den Hertog, et al.
Published: 1 August 2018
World Neurosurgery, Volume 116, pp 402-411.e2;

Chronic subdural hematoma (CSDH) is one of the more frequent pathologic entities in daily neurosurgical practice. Historically, CSDH was considered progressive recurrent bleeding with a traumatic cause. However, recent evidence has suggested a complex intertwined pathway of inflammation, angiogenesis, local coagulopathy, recurrent microbleeds, and exudates. The aim of the present review is to collect existing data on pathophysiology of CSDH to direct further research questions aiming to optimize treatment for the individual patient. We performed a thorough literature search in PubMed, Ovid, EMBASE, CINAHL, and Google scholar, focusing on any aspect of the pathophysiology and nonsurgical treatment of CSDH. After a (minor) traumatic event, the dural border cell layer tears, which leads to the extravasation of cerebrospinal fluid and blood in the subdural space. A cascade of inflammation, impaired coagulation, fibrinolysis, and angiogenesis is set in motion. The most commonly used treatment is surgical drainage. However, because of the pathophysiologic mechanisms, the mortality and high morbidity associated with surgical drainage, drug therapy (dexamethasone, atorvastatin, tranexamic acid, or angiotensin-converting enzyme inhibitors) might be a beneficial alternative in many patients with CSDH. Based on pathophysiologic mechanisms, animal experiments, and small patient studies, medical treatment may play a role in the treatment of CSDH. There is a lack of level I evidence in the nonsurgical treatment of CSDH. Therefore, randomized controlled trials, currently lacking, are needed to assess which treatment is most effective in each individual patient.
, Bing Chen, Liujun Xue, Lei Xia, Xiu Yang, Ming Wei, Xiaobo Hui, Quan Chen, Jinlong Zheng, Zhengming Li, et al.
Experimental and Therapeutic Medicine, Volume 16, pp 959-965;

The present randomized controlled study investigated the differences in the curative effects of twist-drill craniotomy (TDC) and burr-hole craniotomy (BHC) in the treatment of chronic subdural hematoma (CSDH). A total of 40 patients diagnosed with CSDH via head computed tomography (CT) who required surgical decompression from January 2016 to January 2017 were enrolled in the present study, and were randomly divided into a TDC group (n=20) and a BHC group (n=20). The modified Rankin scale (mRS) scores of patients were recorded prior to the operation, and at 48 h and 3 months after the operation. The differences in the mRS score (VmRS) among the groups were calculated using the Mann-Whitney U test. The 40 patients enrolled comprised 33 males and 7 females, and there were no significant differences in the general clinical characteristics between the two groups. In the BHC group, 3 patients had a pre-operative mRS score of 5 points, among which 2 cases died at 32 and 45 days after discharge. In the TDC group, 4 patients had a pre-operative mRS score of 5 points, among which 1 case died of epilepsy and pulmonary infection at 1 month after the operation. No difference in the mortality rate was present between the two groups. During the 3-month follow-up, head CT indicated that the intracranial hematoma in a total of 4 patients, including 3 cases in the TDC group and 1 case in the BHC group, completely disappeared. In the BHC group, 3 cases required a repeated incision and drainage after the first operation, while no secondary operation was required in any of the cases of the TDC group. The average length of stay at the hospital (LOS) after TDC was 9.00±2.91 days, which was significantly shorter than that after BHC (14.75±5.95 days). In the total sample of 40 patients, a longer LOS was associated with a higher risk of secondary operation due to recurrence after discharge. The variation value of the mRS score at 3 months after the operation and its ratio vs. the pre-operative score in the TDC group were significantly different from those in the BHC group, suggesting that the improvement of neurological function after TDC was significantly greater than that after BHC. Although 18 patients (90%) in the TDC group were cured, there was no significant difference from the cure rate in the BHC group [15 patients (75%)]. In conclusion, no significant differences were identified in the cure rate and the mortality rate of patients with CSDH after the two types of surgical treatment. However, the mRS score in the TDC group at 3 months after the operation exhibited a significantly greater improvement compared with that in the BHC group, and the overall LOS in the TDC group was significantly shorter than that in BHC group. Therefore, TDC is superior to BHC in the treatment of CSDH (trial registration no. ChiCTR-INR-16008368).
Hiroaki Matsumoto, Hiroaki Hanayama, Takashi Okada, Yasuo Sakurai, Hiroaki Minami, Atsushi Masuda, Shogo Tominaga, Katsuya Miyaji, Ikuya Yamaura, Yasuhisa Yoshida
Published: 1 March 2018
Journal of Clinical Neuroscience, Volume 49, pp 40-47;

Refractory chronic subdural hematoma (CSDH) is rare but remains a difficulty for neurosurgeons, and no consensus on treatment procedures has been established. To discuss effective surgical procedures for refractory CSDH, we analyzed our surgical procedures and outcomes for refractory CSDH. We defined patients with refractory CSDH as those who presented with two or more recurrences. Fourteen patients with refractory CSDH were analyzed. Eight patients underwent burr-hole irrigation and closed-system drainage alone, four patients received embolization of the middle meningeal artery (MMA), and two patients with organized CSDH underwent large craniotomy with outer membranectomy as the third surgery. Two of the eight patients (25%) treated with burr-hole irrigation and drainage alone showed a third recurrence. No further recurrences were identified in patients treated with embolization of the MMA or craniotomy. However, statistical analysis showed no significant difference in cure rate between patients treated with burr-hole irrigation and drainage alone and patients treated with burr-hole irrigation and drainage with embolization of the MMA (P = .42). Similarly, no significant differences in cure rate were seen between patients treated with burr-hole irrigation and drainage alone and patients treated with craniotomy (P = .62). When selecting a surgical procedure, assessing whether the CSDH is organized is crucial. Embolization of the MMA may be considered as one of the optional treatments for refractory CSDH without organized hematoma. On the other hand, for refractory cases of organized CSDH, hematoma evacuation and outer membranectomy with large craniotomy or mini-craniotomy assisted by an endoscope may be suitable, as previous reports have recommended.
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